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Cullen TS. Embryology, anatomy, and diseases of the umbilicus together with diseases of the urachus. (1916) W. B. Saunders Company, Philadelphia And London.

Online Editor

This historic 1916 textbook by Cullen describes the umbilical region.

Modern Notes: placenta

Historic Embryology - Placenta
1883 Embryonic Membranes \| 1907 Development Atlas \| 1909 \| 1910 Textbook \| 1917 Textbook \| 1921 Textbook \| 1921 Foetal Membranes \|1921 human \| 1921 Pig implantation \| 1922 Single placental artery \| 1923 Placenta Review \| 1939 umbilical cord \| 1943 human and monkey \| 1944 chorionic villus and decidua parietalis \| 1946 placenta ageing \| 1960 first trimester placenta \| 1960 monkey \| 1972 Placental circulation \| Historic Disclaimer

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Pages where the terms "Historic" (textbooks, papers, people, recommendations) appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms, interpretations and recommendations may not reflect our current scientific understanding. (More? Embryology History \| Historic Embryology Papers)

Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus

By

Thomas Stephen Cullen

Associate Professor of Gynecology in the Johns Hopkins University

Assistant Visiting Gynecologist to the Johns Hopkins Hospital

Illustrated By

Max Brodel

W. B. Saunders Company, Philadelphia And London, 1916

This book is affectionately dedicated to my Mother Mary Cullen

Daughter of the late Rev. Thomas and Mary Greene

Born on July 12, 1841, at Polminick, near

Penzance, Cornwall, England

Preface

During the summer of 1904 I saw a case of cancer of the umbilicus with Dr. Jacob L. Winner. Up to that time I had thought that hernia was practically the only lesion to be noted in this locality. The patient did well for a time, but later large intra-abdominal tumors could be felt and finally he died. Xo autopsy was obtained. Histologic examination of the umbilical growth showed that it was an adenocarcinoma.

I was at a loss to explain the presence of glands in this position, and a cursory examination of the text-books failed to elucidate the matter. I could not rid myself of the desire to find out definitely just how an adenocarcinoma could exist in the umbilicus, and several years later, when other and more pressing problems had been completed, I carefully searched the literature for cases of cancer of the umbilicus and was amazed to find the records of many instances.

In the majority of the cases the umbilical growth was secondary to a cancer of the stomach, gall-bladder, intestine, or ovary. Cases of primary adenocarcinoma and of squamous-cell carcinoma of the umbilicus occur, but they are very rare.

During this study I encountered a wealth of material dealing with the omphalomesenteric duct. We have long been familiar with Meckel's diverticulum, but two facts, that the omphalomesenteric duct may be patent throughout its entire extent at birth, and that remnants of the outer end of the duct may give rise to the small umbilical polyps sometimes noted after the cord drops off, have not been commonly appreciated.

The literature is rich in records of devastating infections that prevailed before the era of asepsis. These occurred generally in hospitals, and most often when an epidemic of puerperal sepsis was rampant among the mothers. The descriptions of some of them are intensely graphic, and from the detailed reports of the individual cases one can obtain a wonderful picture of the terminal infections occurring in these infants.

I found a somewhat extensive literature on dermoids of the umbilicus, but on analyzing the cases was obliged to conclude that the majority of these growths represented nothing more than inflammations due to irritation exerted by an umbilical concretion. It was the presence of caseous material and the admixture of wool from the patient's clothing that had led to the erroneous diagnosis.

I found records of cases of Paget's disease, diphtheria, and syphilis of the umbilicus. There is also an extensive literature on the escape of intra- and extraabdominal fluid, usually pus, through the umbilicus, and many cases of umbilical fistula are recorded.

Many umbilical tumors have been reported, some benign, others malignant. I was especially interested in one group of cases. These tumors were small; they always occurred in women; they tended to swell at the menstrual period, and some urachus have been collected, the cases classified, and the appropriate methods of treatment outlined. I trust that this work may help the general practitioner, the pediatrician, and the surgeon to treat more satisfactorily lesions of this heretofore relatively unknown region, unknown, although up to the daj r of birth it is on the main highway between the mother and the child.

Thomas S. Cullen.

The Johns Hopkins Hospital, May, 1916.

List of Illustrations

1. Sagittal Section Showing a Very Early Stage in the Formation of the Umbilicus and allantois 2

2. A More Advanced Stage in the Formation of the Umbilical Region 2

3. A Composite Picture Showing the Formation of the Umbilicus in an Embryo 3

4. A Diagrammatic Representation of a Human Embryo, about 3.5 mm. Long, Show ing the Effect of the Expanding Amnion upon the Yolk-sac and Body-stalk ... 4

5. Sagittal View of a Human Embryo 5 mm. in Length 5

6. Anterior View and Transverse Section of a Human Embryo 7 mm. Long, Showing

the Umbilical Region 6

7. Sagittal Section of the Umbilical Region in an Embryo 7 mm. in Length 7

8. Sagittal View of the Umbilical Region of a Human Embryo 10 mm. in Length 8

9. Graphic Reconstruction of the Umbilical Cord of a Human Embryo 12.5 mm. in

Length 9

10. Anterior View of the Umbilical Cord of a Human Embryo 18 mm. in Length 10

11. Sagittal Section of the Umbilical Region in a Human Embryo 23 mm. in Length .. 11

12. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 3 cm.

Long 12

13. Sagittal Section of the Umbilical Region in a Human Embryo 4.5 cm. in Length .. 13

14. A Graphic Reconstruction of the Umbilical Region of a Human Embryo 4.5 cm.

in Length as Viewed from within the Abdomen 14

15. Sagittal View of a Graphic Reconstruction of the Umbilical Region of a Human

Embryo 5.2 cm. in Length 15

16. Intra-abdominal View of the Umbilical Region of a Human Embryo 6.5 cm. in

Length 17

17. Intra-abdominal View of the Umbilical Region in a Human Embryo 7.5 cm. Long . . 18

18. Intra-abdominal View of the Umbilical Region in a Human Embryo 9 cm. in

Length 18

19. Intra-abdominal View of the Umbilical Region in a Human Embryo 10 cm. in

Length 19

20. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. Long . . 19

21. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in

Length 20

22. Intra-abdominal View of the Umbilical Region in a Human Embryo 12 cm. in

Length 21

23. Cross-section of the Umbilical Cord at the Umbilicus in a Human Embryo 12 cm.

in Length 22

24. Internal View of the Umbilical Region in a Human Embryo 15 cm. Long 23

25. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

26. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

27. A Composite Representation of Abnormal Umbilical Structures, Based on the

Work of Keibel, Lowy, and Others 24

28. The Umbilical Region in a Fetus about Five Months Old Viewed from the Left . . 25

29. Side and Posterior Views of the Umbilical Region in a Fetus of Six to Seven

Months 25

30. Three Diagrams of the Umbilical Ring and Its Significance in the Development

of Ventral Hernia 27

XV

XVI LIST OF ILLUSTRATIONS

Fig. Page

31. The Appearance of the Yolk-sac (Umbilical Vesicle) in a Pregnancy, with the

Embryo 5.5 cm. Long 28

32. The Umbilical Region, the Cord, and the Placenta at Term 29

33. A Diagrammatic Representation of the Umbilical Region of a Fetus at Term .... 32

34. Normal Umbilicus according to Catteau 35

35. A Type of Umbilical Region in the Adult, Viewed from Within 44

36. A Frequent Type of the Umbilical Region in the Adult, Viewed from Within .... 44

37. The Umbilical Region of an Adult, Viewed from Within 45

38. Classic Type of Umbilicus 47

39. Disposition of the Vascular Cords (Usual Type) 48

40. Vascular Cords of the Anastomosing Type, Noted 7 Times in 50 Cases 48

41. Vascular Cord Type, Noted 5 Times in 50 Cases 49

42. Vascular Cords, Noted 5 Times in 50 Cases, Completely Filling the Umbilical

Ring 49

43. Vascular Cords, Noted 3 Times in 50 Cases 49

44. Vascular Cords, Noted in 2 out of 50 Cases 50

45. Umbilical Fascia. Peritoneum in Place 52

46. Umbilical Fascia and Umbilical Mesentery 52

47. Reduplication of the Linea Alba. Peritoneum Removed 52

48. Atrophy of the Umbilical Fascia, Posterior View 53

49. Formation of a Mesentery. Peritoneum in Place 53

50. Mesentery of the Urachus and of the Umbilical Arteries 53

51. Adipose Fringes. From a Well-developed Young Woman. Peritoneum in Place 54

52. Adipose Fringes in a Stout Subject. Peritoneum in Place 54

53. Peritoneal Diverticula. Peritoneum in Place 55

54. Peri-umbilical Fossettes. Peritoneum in Place 55

55. Ovarian Pedicle Passing from Uterus out through a Hernial Ring in the Ab dominal Wall 57

56. Extra-abdominal Multilocular Fibrocystoma of the Ovary 5S

57. An Extra- abdominal Multilocular Fibrocystoma 59

58. Superficial Lymphatics of the Umbilical Region 64

59. The Deep Umbilical Lymphatics as Seen from the Peritoneal Side 65

60. The Umbilical Vessels about the Time of Birth 72

61. The Umbilical Vessels in the Adult 72

62. 63. Method of Treating the Umbilical Stump at Birth 98

64. Nature's Method of Checking Bleeding from the Umbilical Arteries 107

65. An Umbilical Granulation 117

66. The Gradual Atrophy of the Omphalomesenteric Duct 121

67. An Umbilical Polyp Connected with Meckel's Diverticulum by a Fibrous Cord . . 121

68. An Umbilical Polyp Attached to the Small Bowel by a Fibrous Cord 121

69. An Umbilical Polyp on the Prominent Part of an Umbilical Hernia : . . 123

70. A Polypoid Outgrowth from the Umbilicus 129

71. Tubular Glands from the Umbilical Polyp Shown in Fig. 70 129

72. A Diverticular Tumor at the Umbilicus 132

73. A Glandular Tumor from the Umbilicus 132

74. A Glandular Growth at the Umbilicus 133

75. Section in the Long Axis of a Small Umbilical Growth 134

76. Adenoma of the Umbilicus 135

77. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord. 138

78. Ax Umbilical Polyp Attached to a Meckel's Diverticulum by a Fibrous Cord . . . 138

79. An Umbilical Polyp 139

80. A Small Intestinal Polyp Almost Fillingthb Umbilical Depression 139

81. An Umbilical Polyp 140

82. Portion of an Intestinal Polyp Partially Filling the Umbilical Depression .... 141

83. Transverse Section op a Pseudopyloric Congenital Fistula at the Umbilicus . . . . 149

LIST OF ILLUSTRATIONS XV11

Fia. Fage

84. High-power Picture op a Fistulous Tract at the Umbilicus, Showing Glands Re sembling those of the Pylorus 150

85. An Umbilical Fistula Lined with Mucosa Resembling that of the Stomach 150

86. Appearance of the Umbilical Depression in von Rosthorn's Case 152

87. Gastric Mucosa at the Umbilicus 153

88. Appearance of the Umbilicus After Removal of the Stomach Mucosa Seen in

Fig. 87 154

89. Persistence of the Outer End of the Omphalomesenteric Duct 156

90. Atrophy of the Inner End of the Omphalomesenteric Duct 156

91. A Long Umbilical Polyp as a Remnant of the Omphalomesenteric Duct 156

92. Meckel's Diverticulum 159

93. A Meckel's Diverticulum Attached to the Abdominal Wall at the Umbilicus. . 160

94. An Abnormally Large Meckel's Diverticulum 161

95. A Meckel's Diverticulum with a Lobulated Extremity 161

96. A Meckel's Diverticulum with Hernial Protrusions from Its Surface 162

97. A Short Meckel's Diverticulum Springing from the Mesenteric Attachment . . 163

98. An Accessory Pancreas in the Tip of Meckel's Diverticulum 163

99. A Meckel's Diverticulum Completely Tying off a Loop of Small Bowel 164

100. A Diverticulum Tying Off a Loop of Small Bowel 165

101. Strangulation of a Meckel's Diverticulum Causing Volvulus of the Ileum. . . . 166

102. Fatal Intestinal Obstruction Due to the Passage of the Bowel through a

Hole in the Mesentery of a Meckel's Diverticulum .170

103. Inversion of a Meckel's Diverticulum into the Lumen of the Bowel 171

104. A Well-developed Loop of Small Bowel in a Dermoid Cyst of the Ovary 175

105. An Intestinal Cyst 176

106. An Intestinal Cyst Attached to the Umbilicus by a Pedicle but not Connected

with the Bowel 176

107. Volvulus of Meckel's Diverticulum 177

108. An Intestinal Cyst Developing from Meckel's Diverticulum 178

109. Intestinal Cysts in the Abdominal Cavity 182

1 10. An Intramesenteric Cyst 183

111. A Patent Omphalomesenteric Duct 190

112. A Patent Omphalomesenteric Duct with a Polypoid Formation at the Umbilicus . 190

113. A Very Short Omphalomesenteric Duct 190

114. A Patent Omphalomesenteric Duct with a Polyp- like Formation at the Umbil icus 190

1 15. A Patent Omphalomesenteric Duct 192

116. A Patent Omphalomesenteric Duct 193

1 17. A Patent Omphalomesenteric Duct 197

118. A Patent Omphalomesenteric Duct 197

119. A Patent Omphalomesenteric Duct 202

120. A Patent Omphalomesenteric Duct 205

121. A Patent Omphalomesenteric Duct 206

122. Part of a Patent Omphalomesenteric Duct 206

123. Intestinal Mucosa Covering the Cutaneous or Umbilical End of a Patent Om phalomesenteric Duct 207

124. An Umbilical Polyp and a Fibrous Nodule at the Umbilicus. There was Origin ally a Patent Omphalomesenteric Duct 209

125. Longitudinal Section through the Entire Center of a Partially Closed Om phalomesenteric Duct 209

126. A Patent Omphalomesenteric Duct 211

127. A Patent Omphalomesenteric Duct Opening at the Base of the Umbilical Cord . . 216

128. A Patent Omphalomesenteric Duct 216

129. A Patent Omphalomesenteric Duct as Seen from the Abdominal Cavity 216

130. Inversion of the Bowel through a Patent Omphalomesenteric Duct Opening on the Side of the Umbilical Cord 219

131. A Patent Omphalomesenteric Duct of Large Diameter 224

132. Commencing Prolapsus of Small Bowel through a Patent Omphalomesenteric Duct 224

133. Partial Prolapsus of the Small Bowel through the Omphalomesenteric Duct . . . 224

134. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct .... 224

135. Complete Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 225

136. Prolapsus of the Small Bowel through the Patent Omphalomesenteric Duct, and an Umbilical Hernia between the Loops of Prolapsed Bowel 225

137. Prolapse of the Small Bowel through an Open Omphalomesenteric Duct 227

138. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct 228

139. Prolapsus of the Bowel through a Patent Omphalomesenteric Duct, with Sec ondary Complications 229

140. Prolapsus and Inversion of the Intestine through a Patent Omphalomesenteric Duct 230

141. Prolapsus of the Bowel through the Patent Omphalomesenteric Duct 232

142. A Small Cyst of the Umbilicus Due to a Remnant of the Omphalomesenteric Duct 238

143. Small Cyst of the Abdominal Wall Due to a Remnant of the Omphalomesenteric Duct 238

144. A Small Intestinal Cyst Lying between the Peritoneum and the Recti 240

145. An Omphalomesenteric Duct Originating from the Concave Side of the Bowel and Attached to the Umbilicus by a Fibrous Cord 243

146. A Remnant of an Omphalomesenteric Duct Causing Fatal Intestinal Obstruction 245

147. A Small Umbilical Concretion 249

148. Acute Inflammation of the Umbilicus Due to an Accumulation of Sebaceous Material 249

149. Cholesteatoma from the Umbilicus in Case 1 251

150. Cholesteatoma from Case 2 251

151. A Connective-tissue Projection Really Representing a Small Fibroma in the Floor of the Umbilicus 252

152. Enlargement of Fig. 151 252

153. Subumbilical Phlegmon 262

154. The Subumbilical Space 264

155. Paget's Disease of the Umbilicus 270

156. Paget's Disease of the U/mbilicus 270

157. Paget's Disease of the Umbilicus 271

158. Paget's Disease of the Umbilicus 274

159. The Appearance in a Case of Paget's Disease of the Umbilicus After Treatment with Radium 275

160. Syphilis of the Umbilicus 284

161. Atrophic Tuberculid Starting at the Umbilicus 286

162. Leakage from an Abdominal Aneurysm Producing a Temporary Abdominal Tumor; Subsequent Escape of the Blood into the Right Renal Pocket 288

163. The Manner in Which a Periprostatic Abscess may Occasionally Rupture at the Umbilicus 289

164. Escape of Pleural Fluid from the Umbilicus 289

165. The Opening of a Broad Ligament Abscess at the Umbilicus 290

166. Abdominal Pregnancy with Spontaneous Escape of Liquor Amnii from the Umbilicus 348

167. Small Papilloma in the Umbilical Depression 365

168. A Shall Umbilical Tumor Containing Glands and Stroma Identical with Those of the Uterine Mucosa 376

169. Glands from a Small U\iisiLirALTuMOR 377

170. Typical Uterine Mucosa in a Small Umbilical Tumor. An Enlargement of Area B in Fig. 168 378

171. Glands in a Small Umbilical Tumor 379

172. Dilated Glands in a Small Umbilical Tumor 380

173. Dichotomous Branching of Glands in a Small Umbilical Tumor 381

174. Uterine Glands in an Umbilical Tumor 381

175. Gland Hypertrophy in a Small Umbilical Tumor 382

176. A Tumor of the Umbilicus Composed Partly of Hypertrophic Sweat-glands 383

177. Uterine Mucosa in an Umbilical Tumor 384

178. A Small Umbilical Tumor Containing Numerous Glands 388

179. Glands in a Small Umbilical Tumor 389

180. An Adenomyoma in the Abdominal Wall Near the Anterior Iliac Spine 394

181. A Small Umbilical Tumor Containing Glands Similar to Those of the Body of the Uterus 396

182. Adenomyoma of the Umbilicus 397

183. A Group of Sweat-glands in an Umbilical Tumor 398

184. Appearance of the Carcinomatous Umbilicus After Removal 424

185. Carcinoma of the Umbilicus Secondary to Carcinoma of the Ovaries 432

186. A Malignant Growth of the Umbilicus, Apparently a Carcinoma Secondary to Some Abdominal Growth 439

187. Adenocarcinoma of the Umbilicus Secondary to an Intra-abdominal Growth .... 440

188. Adenocarcinoma of the Umbilicus 441

189. A Section Showing Carcinoma of the Right Inguinal Glands 442

190. Secondary Carcinoma of the Umbilicus 443

191. Telangiectatic Myxosarcoma of the Umbilicus 450

192. Appearance of the Umbilicus After Removal of the Tumor Shown in Fig. 191. . 450

193. Myxosarcoma of the Umbilicus 451

194. Telangiectatic Myxosarcoma Projecting from the Right Side of the Umbilicus . . 452

195. A Telangiectatic Myxosarcoma 452

196. A Case of Congenital Umbilical Hernia 460

197. An Amniotic Hernia 462

198. Several Loops of Bowel Which Lay Outside the Umbilicus and were Nipped Off During Fetal Life. The Child Lived a Short Time After Birth 464

199. A Serous Umbilical Hernia 469

200. Freeing the Umbilical Hernial Sac from the Abdomen 472

201. Closure of the Hernial Opening at the Umbilicus 473

202. Closure of the Hernial Opening at the Umbilicus 474

203. An Umbilical Hernia Associated with Marked Prolapsus of the Abdominal Wall 475

204. An Umbilical Hernia and a Markedly Pendulous Abdomen in a Patient Weighing 464 Pounds 476

205. The Abdominal Scar After the Removal of a Very Large Area of Fat 477

206. An Umbilical Cyst 478

207. Exstrophy of the Bladder Opening at or Near the Umbilicus 482

208. Exstrophy of the Bladder. A side View of the Case Depicted in Fig. 207, Showing the Relative Distance from the Symphysis to the Opening in the Abdominal Wall : 483

209. Exstrophy of the Bladder 483

210. Escape of Urine from the Umbilicus When the Inner Urethral Orifice Is Blocked by a Membrane 488

211. A Patent Urachus with a Mushroom-like Projection at the Umbilicus 489

212. A Patent Urachus with a Penile Projection at the Umbilicus 489

213. The Appearance of the Umbilicus in a Case in Which both a Patent Omphalomesenteric Duct and a Patent Urachus Existed 493

214. Cross-section of the Patent Omphalomesenteric Duct and of the Patent Urachus in the Same Child 493

215. A Picture of the Child Three Weeks After Removal of a Patent Omphalomesenteric Duct and a Patulous Urachus 494

216. A Patent Urachus 497

217. A Urachus Open from Bladder to Umbilicus 498

218. An Open Urachus 499

219. Escape of Urine from the Umbilicus Due to a Patent Urachus 502

220. A Patent Urachus with a Penile Projection at the Umbilicus 505

221. A Ring-shaped Vesical Calculus with a Fine Hair in Its Axis 507

222. A Partially Patent Urachus 515

223. A Patent Urachus 517

224. A Portion of a Urachus Seven Times Enlarged, with Numerous Large and Small Dilatations 518

225. Portion of a Urachus Ten Times Enlarged 518

226. Cysts of the Urachus Arranged Like a String of Pearls .- 520

227. Spindle-Shaped Dilatations of the Urachus 520

228. A Small Cyst of the Urachus 532

229. A Patent Urachus 534

230. A Multilocular Cyst of the Urachus 535

231. Section of a Patent Urachus .' 536

232. Transverse Section of a Patent Urachus 537

233. A Small Cyst of the Urachus 538

234. A Diffuse Neuroma of the Bladder 542

235. Cut Surface of the Bladder Showing a Diffuse Neuroma of Its Walls 543

236. A Diffuse Neuroma Forming a Mantle Around the Cavity of the Bladder 544

237. Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus 551

238. Section of the Segment of Urachus Which Passed between the Bladder and the Cyst- wall, as Seen under a Low Power 552

239. The Abdominal Contour in a Case of Very Large Urachal Cyst 558

240. A Urachal Cyst Turned Inside Out and Showing Papillary Masses, Particularly in the Lower Part of the Picture 559

241. Infected Urachal Remains 568

242. An Infected Urachus Opening between the Umbilicus and Bladder 570

243. Urachal Cyst 576

244. A Dilated Urachus Communicating with the Bladder 579

245. Large Accumulation of Urine in a Partially Patent Urachus 579

246. An Infected Urachus Opening at the Umbilicus 580

247. A Patent Urachus Dilated in Its Middle Portion 580

248. Accumulation of a Large Quantity of Urine in a Urachal Pouch 581

249. Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac 584

250. A Phosphatic Deposit on the End of a Long Bone 585

251. A Dilated Urachus Communicating with the Bladder 598

252. Urachal Cyst 599

253. Urachal Cyst 603

254. Urachal Cyst 603

255. A Patent Urachus Containing a Vesical Calculus 625

256. Carcinoma of the Patent Urachus 632

257. A Multilocular and Malignant Cyst of the Urachus 637

258. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus 638

259. Giant-cells in the Wall of an Adenocarcinoma of the Urachus 639

260. Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Urachus. . .640-641

261. Adenocarcinoma of the Urachus 642

262. A Papillary-like Area i.\ an Adkxocarcinomatous Cystofthe Urachus 643

263. Metastasis from Adenocarcinoma of the Urachus 644

264. An Umbilical Cyst 645

265. \\ aj.i of an Umbilical Cyst 645

266. Giant-cells in the Wall of an Umbilical Cyst 646

267. Tuberculosis of the Urachus 652

268. An Area Suggesting a Tubercle 653

269. A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus 654

List of Plates

I. Drawings of Normal Umbilici 40

II. Drawings of Normal Umbilici 41

III. Drawings of Normal Umbilici 42

IV. Drawings of Normal Umbilici 43

V. Cancer of the Umbilicus Apparently Secondary to a Tumor of the Ovary. .434-435

VI. Umbilical Hernia 466-467

VII. Exstrophy of the Bladder 484-485

Chapter XXXII. Large Urachal Cysts

Historic sketch.

Symptoms.

Differential diagnosis; personal observations on a large diffuse neuroma of the bladder.

Treatment.

Detailed report of large, non-infected urachal cysts.

The small urachal cysts that we have considered rarely reached 1 cm. in diameter, and were naturally readily overlooked clinically. Probably one of the first urachal cysts ever opened was the one observed by Peu in 1648, and recorded in his Pratique des Accouchements, 1694, p. 38, and recently referred to by Wutz. The patient was a child two hours old. Situated at the umbilicus was a tumor the size of a pigeon's egg. It was opened, and a serum-like fluid escaped. This proved to be urine, and on the following morning urine escaped in a jet from the umbilicus..

Atlee, in 1873, in his treatise on Ovarian Tumors, reported the case of a girl eighteen years old. When opening the abdomen for the removal of an ovarian tumor he accidentally incised a urachal cyst containing an ounce of fluid resembling ordinary ascitic fluid.

Von Recklinghausen in 1902 demonstrated a polycystic tumor the size of a walnut which had been excised from a man thirty years old.

E. R. LeCount found a urachal cyst the size of an orange while making an autopsy on a man fifty-two years of age.

Interesting articles on urachal cysts have been written by Rippmann (1872), Wolff (1873), Scholz (1878), Schaad (1886), Tait (1886), Dossekker (1893), Douglas (1897), and others, and in 1906 the splendid monograph of Weiser appeared.

These cysts are naturally first noted in the mid-line between the umbilicus and pubes. They lie in the anterior abdominal wall just external to the peritoneum.

Size. — In the beginning they are relatively small, as in von Recklinghausen's, Atlee's, and LeCount's cases. As a rule, the increase in size is only gradual, but in a few instances the growth has been very rapid. They rarely extend above the umbilicus, but in some instances have reached as far as the xiphoid. Among the largest cysts are those recorded by Pratt and Bond, Macdonald, Rippmann, and Tait. In Pratt and Bond's case the cyst reached upward beneath the liver. Macdonald' s patient had a markedly distended abdomen; it was firm and rather flat as far as the ensiform cartilage. In Tait's Case 1, 30 pints of fluid were evacuated at operation. Rippmann's was probably the largest on record. At autopsy the cyst was found to contain 52 liters of fluid weighing 100 pounds.

The cyst may or may not burrow beneath the bladder, and encroach on the vaginal vault. It is sometimes attached to the bladder by the urachal cord, and where the tumor has reached large proportions, it is usually adherent to the umbilicus.

The cyst-walls vary considerably in thickness. Some are verj^ thin, others may be from 1 to 4 mm. thick.

539

540 THE UMBILICUS AND ITS DISEASES.

The inner surface of the cyst is usually smooth. Sometimes coagulated cyst fluid clings to its walls. In Macdonald's case papillary masses were found springing from the inner surface of the cyst (Fig. 240, p. 559).

As these cysts are due to dilatations of the urachus, we should naturally expect to find them lined with transitional epithelium. When the cysts are small, the lining with transitional epithelium is often found, but in the large cysts, there not being enough to cover the whole surface, remnants of this transitional epithelium are often found only over certain areas on the cyst-wall. The walls are composed of fibrous tissue and contain a varying quantity of non-striped muscle. In Tait's Case XI calcareous particles were found scattered throughout the wall of the cyst.

Cyst Fluid. — The character of the fluid contained in urachal cysts varies considerably. Sometimes it is pale yellow and limpid, closely resembling ascitic fluid. In other cysts it is yellow and transparent or tenacious and ropy. The fluid may be of a pale-green color. In some cysts it is brown or of a chocolate color; or it may be thin and with a hemorrhagic tint. Whether the fluid be thin and clear, or dark and turbid, it often contains large clumps of coagulated lymph or fibrin. Such masses have been referred to by some writers as "necrotic lymph " or cheesy masses. They are strongly suggestive of the coagulated material often noted in ovarian cysts. The cyst fluid contains albumin and mucus. On histologic examination exfoliated squamous epithelium, fat-droplets, and cholesterin crystals are often noted.

SYMPTOMS.

Sex. — Of the cases of simple uncomplicated and non-infected urachal cysts here recorded, and in which we were able to obtain definite data as to the sex, 16 were in women and 5 in men.

Age. — The youngest patient was six years and the oldest fifty-four. The accompanying table furnishes the following data:

Six years of age 1 case

Between ten and twenty years 1 "

" twenty and thirty years 1 "

" thirty and forty years 7 cases

" forty and fifty years 3 "

" fifty and sixty years 2 "

The first symptom is usually enlargement of the lower part of the abdomen. This, as a rule, is in the mid-line, but the swelling, sometimes accompanied by pain, may first be noticed in the right iliac fossa, and the picture may strongly suggest an appendicitis.

With the increase in abdominal girth there may be a moderate degree of indigestion, and where the cyst has reached large proportions, there has been dyspnea. Some of the patients have become progressively emaciated and have lost in strength.

Micturition has been normal in some, frequent in others. It is but natural that the bladder should be markedly encroached upon in some cases, particularly as the excursus of the tumor is limited, on the one side by the peritoneum, and on the other by the anterior abdominal wall.

Pain has been a marked feature in some cases, absent in others. The pain is probably in a measure due to pressure on the terminal sensory nerve-trunks, owing

LARGE URACHAL CYSTS. 541

to the tension under which the cyst develops, confined, as it is, between the layers of the abdominal wall. But it must also be remembered that the cyst is separated from the abdominal contents only by a thin peritoneum, and consequently the slightest inflammation of the cyst-wall must readily extend to the peritoneum and not only produce pain, but also cause the omentum or some other abdominal structure to become adherent to the abdominal wall over the cyst. Such a condition was noted in Carroll's case, and also in one recorded by Doran.

On physical examination an abdominal swelling is noted. This may extend over the entire abdomen, or be limited to the lower portion. Although the tumor may be exceedingly large, there exists a certain amount of repression of the abdominal wall, due to the tonic contraction of the recti muscles. When the patient is anesthetized and the recti muscles are relaxed, instead of being board-like, the abdomen may become quite soft, and the cystic tumor can then be readily detected. If the abdominal walls are naturally tense, the difficulties in making an accurate diagnosis are augmented. In some cases definite fluctuation can be elicited.

DIFFERENTIAL DIAGNOSIS.

Urachal cysts have been diagnosed as a distended bladder, as ascites, as an appendicitis with abscess formation, as a cyst with or -without twisting of the pedicle, as a localized peritonitis with a serous exudate under the anterior abdominal wall, and as a tuberculous peritonitis.

The distended bladder is readily emptied, and the ascites relieved by paracentesis. With the patient asleep, it is relatively easy to outline the cyst and to differentiate it by the absence of the induration, usually associated with an appendix abscess. Furthermore, with the abscess there is likely to be a history of an elevation of temperature and of a definite leukocytosis.

An ovarian cyst, whether mobile or twisted, lies much farther back in the abdomen and can be separated from the anterior abdominal wall, particularly when the patient is under narcosis. The differentiation from a localized peritonitis or from a tuberculous peritonitis is not so easy, particularly when the patient has become emaciated. Even in these cases, however, when the patient is asleep, the sharp outlines of the urachal cyst are readily distinguishable from the rather diffuse cystic accumulation occurring with a peritonitis. Again, in the case of a urachal cyst, moving it from side to side is likely to produce traction on the umbilicus. With an aspirating needle one can readily remove some of the cyst fluid and thus usually settle the diagnosis.

The following case that recently came under my notice is of such interest in connection with the differential diagnosis of urachal cysts that I shall report its salient features.

A Tremendously Thickened B 1 a d d e r - w a 1 1 Producing a Tumor Reaching Almost to the Umbilicus and Simulating a Urachal Cyst. — The great thickening of the vesical wall was due to a diffuse neuroma. I shall refer to this case very briefly, as Dr. Welch and I will report it in detail elsewhere.

Surg. No. 34093. P. B., a colored boy three years and seven months old. was admitted to the surgical service of the Johns Hopkins Hospital on March 9, 1914. for an ununited fracture of the left tibia and fibula. Dr. Heuer wired the ununited

542

THE UMBILICUS AND ITS DISEASES.

fracture, and the boy made an uneventful recovery. When he entered the hospital it was noted that he had a firm mass extending upward from the symphysis to within 2 cm. of the umbilicus. This mass was broad below and rather narrow near

« 3 1 5

Fig. 234. — A Diffuse Neuroma of the Bladder. (After William H. Welch and Thomas S. Cullen.) The picture shows the appearance of the bladder when the abdomen was opened. The contracted viscus extended almost to the umbilicus, was large and exceedingly hard, and even after it had been brought out of the abdomen, it was almost impossible to realize that it was the bladder. When the bladder was lifted up, it was found that the right ureter was 8 mm. in diameter. The left ureter was slightly enlarged. The surface of the bladder was covered with great congeries of what appeared to be small and tortuous vessels. These were noted at once, but were particularly well seen when the peritoneum was stripped back. Subsequent histologic examination showed that most of these tortuous cords were nerves. The remnant of the urachus was larger than usual. Not knowing at the time the unusual character of the growth, I cut into it and found that the tumor was caused by a tremendous thickening of the bladderwall. For the appearance of the cut bladder-wall see Fig. 235; for the histologic picture see Fig. 236.

the umbilicus. Through the lax abdominal walls it could be readily grasped with the hand. Micturition was normal, and when the bladder was empty, this tumor diminished little, if any, in size.

It seemed to be a urachal tumor of some kind, and Professor Halsted, knowing

LARGE URACHAL CYSTS.

543

that I was much interested in urachal remains, kindly transferred the case to the Gynecologic Department.

Operation (March 28, 1914). — Feeling confident that we were dealing with a

Fig. 235. — Cut Surface of the Bladder Showing a Diffuse Neuroma of its Walls. (After William H. Welch and Thomas S. Cullen.) The figure shows the lower part of the bladder seen in Fig. 234, after the top had been removed. The bladderwalls protruded into the cavity, rendering it very small. The inner surface at this point was covered over with only.a single layer of epithelium, which stained very faintly. All trace of the transitional epithelium was wanting in the sections examined. The bladder-walls in the portion removed varied from 1 to 3 cm. in thickness, and everywhere this coarse and tortuous texture was the striking characteristic. A low-power section through the bladder-wall showed an abundance of nerves on the outer surface. There was a muscular zone with nerve-bundles scattered throughout it, and an inner zone, varying from 1 to 2 cm. broad, consisting almost entirely of nerve elements. (See Fig. 236.)

urachal tumor, I made a median incision from the umbilicus to the symphysis, and at once encountered the tumor seen in Fig. 234. It was very firm, and over a large area was covered with peritoneum. Attached to its upper end was what appeared to be the urachal cord. Immediately beneath the peritoneum of the tumor were

544

THE UMBILICUS AND ITS DISEASES.

Nerves

Tumor

Bladder muscle

Fig. 236. — A Diffuse Neuroma Forming a Mantle Abound the Cavity of the Bladder. (After William H. Welch and Thomas S. Cullen.) Surg. No. 34093. Service of Professor William S. Halsted, Johns Hopkins Hospital. The section has been taken through the top of the bladder seen in Fig. 234. It embraces both walls of the bladder, and near the center the slit-like vesical lumen is visible. This photomicrograph shows numerous nerve-trunks on the outer surface of the bladder. The white areas scattered throughout the bladder muscle are also nerves. Surrounding the bladder cavity is a mantle composed almost entirely of nerves. This nerve zone varied from 1 to 2 cm. in thickness. The mucosa of the bladder in this vicinity was in most places reduced to one layer of epithelial cells that were cuboid or flat. (Iron. hematoxylin. Photomicrograph by Mr. Herman Schapiro.)

LARGE URACHAL CYSTS. 545

numerous small, tortuous cords. The obliterated hypogastric remains were unusually large'.

The ureter on the left side was normal in size; that on the right, fully 8 mm. in diameter. It was evident that this tumor either lay as a cap on the top of the bladder or that it formed an integral part of the bladder-wall. After carefully walling it off, I cut into it and found that we were dealing with a greatly thickened bladderwall. Fig. 235 shows the proximal portion of the wall on section. The inner surface of the bladder was thrown into folds, and its mucosa was exceedingly thin. The bladder-wall was markedly changed, being coarse in texture, due to the crosssection of many cords which emerged from the surface. Only near the peritoneal surface was there any semblance of normal bladder muscle. The walls of the bladder were approximated with considerable difficulty, and sutured, and a drain was laid down to the peritoneum. After the operation the boy did well for several hours; he then developed nausea, vomiting, abdominal distention, and tenderness; his temperature ranged from 100.4° to 103.8° F. and his pulse was very rapid.

On April 1st it was deemed advisable to do an enterostomy. He was given a few whiffs of gas, but died before any operative procedure could be carried out. Much to our regret no autopsy could be obtained, but the abdomen was sufficiently opened to see that peritonitis existed.

Examination of the portion of the bladder removed showed that its walls varied from 1 to 3 cm. in thickness, the extreme degree of thickening being more marked in the posterior vesical wall and at the top of the bladder. Wherever the thickening was marked, this very unusual and coarse appearance was noted.

Fig. 236 is a photomicrograph of a section taken through the top of the bladder. It embraces both walls and the lumen of the bladder. On the outer surface of the bladder are a large number of nerves. These represent the tortuous cords noted at operation. The muscular walls of the bladder are still well preserved, but penetrating here and there are large nerves. Separating the muscle from the bladder mucosa is a zone consisting entirely of nerve elements. In other words, surrounding the bladder cavity in this region is a mantle of nerve tissue varying from 1 to 2 cm. in thickness. We are indebted to Mr. Charles Miller, the technician in Professor Mall's department, for preparing many exquisite sections showing the appearances with the various nerve-stains. These findings will be reported in detail at a later date.

The bladder mucosa in the portion removed was in some places composed of several layers of transitional cells, but in most places the epithelium was but one layer thick and almost flat, and the nerves came up to and encroached upon the epithelium.

Had I, prior to operation, for a moment dreamed that this was not a urachal tumor, 'the bladder would have been at once filled with thorium and x-rayed. Knowing what we do now, we are not in the least surprised that such a bladder would be very slow to heal after being incised. The broad inner zone consisted almost entirely of nerves, and in addition had a very meager blood-supply.

This is the only bladder tumor of this character with which we are familiar; a mistake in diagnosis of this kind will rarely occur.

36

546 THE UMBILICUS AND ITS DISEASES.

TREATMENT OF URACHAL CYSTS.

A median incision, commencing just below the umbilicus and extending to the pubes, will be sufficient to expose a urachal cyst of moderate size. As soon as the recti muscles are separated, the cyst will come into view. Sometimes it is infected and shows signs of inflammation. It is usually loosely adherent to the peritoneum, and can be readily shelled out. Sometimes it is rather firmly adherent to the posterior surface of the bladder. In those cases in which the urachus is rather thick and passes directly into the cyst, it is well to treat it as a pervious cord and to ligate it with Pagenstecher thread and cover this in turn with catgut, to prevent the possible development of a urinary fistula in the lower angle of the abdominal wound.

If the urachal cyst extends upward beyond the umbilicus, it is wise, when making the abdominal incision, to encircle the umbilicus, as this is often adherent to the cyst and should be removed with it.

In some cases it has been found possible to remove the cyst without opening the abdominal cavity. In others the cyst had become adherent to the omentum, and it was necessary to liberate the omental adhesions before the tumor could be removed.

When the cyst is exceptionally large, the peritoneum has of necessity been widely separated from the anterior abdominal wall. After operation the normal intimate relation is usually restored, but that this does not always happen is evident from Douglas's case. After drawing off 25 pints of clear fluid, Douglas readily separated the cyst-wall. The area of peritoneum separated from the parietes extended from about three inches above the umbilicus to the symphysis. It was observed that the peritoneum sank away from the parietes, but, thinking that when the abdominal wound was closed the intra-abdominal pressure would bring it into apposition with the abdominal wall, Douglas made no effort to stitch it there. The abdominal wound was closed in the usual manner and a firm compress was applied. The patient left the operating room in a remarkably good condition. Twenty-four hours later her temperature was 99.4° F., her pulse 136, respirations, 30. She was nauseated, vomited slightly, and there was some epigastric distention. She became dull and roused only when vomiting. Her condition rapidly grew worse, and she died forty-six hours after operation.

At autopsy the entire detached peritoneum on the right side was found to be gangrenous. There had been no hemorrhage, but there' was a little effusion between the peritoneum and abdominal wall. The peritoneal cavity contained a little brown serous effusion, but no pus or lymph.

Tait also reported a death in one of his large cyst cases. The cause could not beascertained, as no autopsy was obtainable.

As a rule, non-infected urachal cysts can be removed with little clanger. If very large, it may in rare instances be advisable merely to drain them and allow the sac to contract down gradually. It can then be removed with less danger of injury to the peritoneum. On the other hand, the adhesions at the second operation are liable to be much denser.

Where the peritoneum has been widely denuded, it may be tacked to the abdominal wall with several delicate catgut sutures; or one or two delicate protective drains may be carried down to the peritoneum, not only providing for the escape of any slight amount of fluid that may accumulate, but also allowing the air to escape and tending to make the abdominal walls flatten down on the peritoneum.

LARGE URACHAL CYSTS. 547

DETAILED REPORT OF LARGE, NON-INFECTED URACHAL CYSTS.

This list includes those cases in which little or no infection existed. Tait, in his article published in 1886, recorded a relatively large number of cases. The majority of these and some others were rather indefinite and have purposely been omitted.

The cyst in Schaad's case was probably urachal in origin, but it was lined with high cylindric epithelium; and as glands opened into it, its origin from remnants of the omphalomesenteric duct cannot be absolutely excluded.

A Urachal Cyst. — Atlee,* on opening the abdomen for the removal of an ovarian tumor in a girl eighteen years of age, found a urinary pouch in the linea alba. This he accidentally divided with the knife. The abdominal walls were very thick, vascular, and remarkably muscular. Between the muscle and the peritoneum he opened a small cyst from which about one ounce of yellowish liquid, resembling ordinary ascitic fluid, escaped. The posterior wall of the sac was cut through and the peritoneum opened. There were no adhesions. The bladder occupied the normal position. On the sixth day the dressings were moist, and by the end of a month Dr. Fay, who looked after the case, felt sure that the fluid was urine. The patient was advised to empty the bladder frequently, and the discharge soon ceased.

"The only conclusion possible was that we were dealing with a dilated urachus, which, although closed at the umbilicus, had from birth maintained a communication with the bladder."

A Urachal C y s t . f — "I. F., aged six years; Newcomerstown, Ohio. Physician, Dr. Hosick. The patient had been taken suddenly sick about three weeks before. The pain seemed to be in the neighborhood of the appendix, but somewhat below McBurney's point. Slight elevation of temperature. Thighs flexed. Amount of pain quite variable. Bowels regular. No appetite. A little before she came to the hospital the abdomen became much distended and painful. Pulse more rapid. Temperature, 100° F. The presumptive diagnosis had been appendicitis with enormous abscess formation. When the patient reached the hospital (May 7, 1911), the abdomen was considerably distended and tender throughout, and with distinct fluctuation. There was perhaps a little more tenderness in the appendix region than elsewhere, but this was not marked. Diagnosis, very doubtful, but the case clearly one for exploration.

"When the patient was under the anesthetic I could determine nothing more about the case. No lump in the region of the appendix. Made the usual median incision. As soon as the incision was made there was an escape of a large amountof rather thin, yellow, odorless fluid. The opening was enlarged, and the cavity thoroughly flushed out, the water bringing out a large amount of what seemed to be necrotic lymph. The cavity was found to be bounded below by the pelvis, above by probably the transverse colon and the stomach. It extended on each side clear to the flanks. The intestines were crowded back by the posterior wall of the cyst. The uterus in this case could be readily felt, though infantile in size, below the membrane. Introduced drainage, with partial closure of the incision. The patient made a smooth convalescence and returned home in the usual time, with distinct warning as to the probability of a hernia.

Atlee, Washington L. : Ovarian Tumors, Philadelphia, Lippincott, 1873, 50.

t Baldwin: Large Cysts of the Urachus. Surg., Gyn. and Obst., 1912, xiv, 636.

548 THE UMBILICUS AND ITS DISEASES.

" September 3, 1911, patient returned with her mother because they had noticed a beginning hernia. The hernia was operated upon the next day. I made an incision directly through the old scar, dissecting down very cautiously, as I expected to find extensive adhesions. On finally opening the peritoneum I found that the abdominal contents were in every respect absolutely normal, except for two cobweb adhesions of the omentum to the anterior abdominal wall. The appendix was brought up and found to be entirely normal; was removed on general principles. Pelvic organs normal. In fact, had one not familiar with the previous history of the case made the operation, he would have found nothing whatever to suggest any previous trouble in the abdomen. In other words, the sac had absolutely disappeared. The bladder, however, seemed to be a little higher up than usual, though even that was not positive."

Large Urachal Cysts. — Dr. Bantock* said he was sure he was expressing the sentiments of every one present when he desired to offer the thanks of the Society to their President [Lawson Tait] for the very remarkable and interesting paper which he had just read. The cases were of remarkable interest, but he feared there was no one who could discuss the subject from experience. The paper was one for future perusal and careful study. He at least was not prepared to discuss it, but he thought he might refer to two cases of which he was reminded by some of the cases related by the President.

The first case was that of a married woman, aged thirty, the mother of two children. On dividing the parietes, Bantock opened into a cyst containing 25 pints of a thick, grumous fluid, with a very decided biliary tinge. When the whole of the fluid was removed, the cyst was found to be unilocular, and looking down into the pelvis was like looking into one's hat, so completely did the walls of the cyst line the pelvic cavity. After separating what appeared to be cyst-wall from the parietes on each side, and cutting away what was thus separated, recognizing the hopelessness of proceeding further, he washed out the cyst with a solution of iodin and closed the wound, leaving a drainage-tube passing down to the bottom of the pouch. Although the separation of what was taken as cyst-wall was carried beyond the umbilicus, the peritoneal cavity was not opened. A thick, pultaceous fluid of the color of mustard came from the cavity for many weeks, but the patient was discharged quite well at the end of about two months. Bantock had lately seen this patient in perfect health. He adds that the source of the brilliant yellow color of the discharge was still a puzzle to him.

The second case was that of a married woman, thirty-seven years of age, the mother of three children. The history told that she was taken ill on January 10th with violent sickness and pain all over the stomach. She was laid up and became feverish; the pain being severe for five days and the sickness for two days. The abdomen gradually got larger, and about the end of February she was tapped of rather more than half a gallon of a thickish, pale-yellowish fluid. In about a month more she was tapped again to the extent of three pints of a thicker fluid, and recommended to apply poultices. Shortly after this the puncture-hole opened and discharge came away. She then presented herself at the out-patient department of the Samaritan Hospital, under the care of Dr. Amand Routh, with whom Bantock saw her. There was then a fistulous opening about two inches below the umbilicus, in the middle line, and an ordinary surgical probe passed in for its whole length. She

Bantock: From Tait's article, Brit. Gyn. Jour., 1886-87, ii, 348.

LARGE URACHAL CYSTS. 549

was admitted into the hospital on July 20th, and Bantock thought he had to deal with a multilocular tumor of which a central cyst had suppurated, as on withdrawing the probe no discharge followed. On July 27th he divided the parietes by a double elliptic incision, with the view of cutting out the fistulous tract, and was not a little surprised to find, on completing the division on one side, that he had opened directly into a unilocular cyst containing from three to four pints of a purulent-looking fluid. On further examination he found the same condition of things as in the first case, and, recognizing the inadvisability of proceeding further, he thoroughly washed out the cavity with plain warm water and closed the wound, leaving in a glass drainagetube. The patient presented herself at the hospital two or three weeks before the meeting of the society and was in perfect health. In this case the uterus was low down, pressed forward, and fixed. Bantock said that he was as much at a loss to explain the relations and origin of this cyst as in the first instance, but he thought they were worthy of being related in connection with the very remarkable cases read by the President.

Probably a Urachal Cyst. — Bryant,* in discussing Doran's paper, reported two cases. In Case 1, on operating on what had been diagnosed as an ovarian cyst, he suddenly opened into a cyst from which serosanguineous fluid escaped. This was in front of the peritoneum, and was with difficulty separated from the bladder. When this had been done, the cyst came away in his hand, and it was clear that it had no pedicle nor any connection with the broad ligament.

A Cystic Urachus. — Carroll's! patient was a woman thirty-four years old. She had been well until twenty-three. After that she had had attacks of abdominal pain, loss of weight, and on one occasion inflammation of the bladder.

On examination an induration was found extending from the umbilicus two to three inches to the right, and downward for three or four inches. The tumor was apparently too near the umbilicus to be of appendiceal origin.

Roswell Park made a median incision below the umbilicus. The tissues were very dense and difficult to cut. A sac was opened and fluid escaped. The incision was enlarged, and a finger introduced. The tumor was found to be a cystic urachus. A connection with the bladder could be traced, but a probe could not be passed. The connection was tied off and the cyst dissected out. There were a number of adhesions between the tumor and the omentum. The patient made a good recovery. "The probable explanation of the attacks seemed to be an oozing of urine into the upper or cystic part of the urachus, and as there was no egress for the fluid once gathered, it was absorbed into the system, causing a toxemia."

A Large Cyst of the Urachus. £ — The patient was a girl, twenty years of age. The tumor had first been noticed a year before admission. It had increased greatly in size in the last four months. It had commenced as a painful point in the right iliac fossa. On account of the patient's emaciation and the increase in abdominal girth the physician had diagnosed tuberculous peritonitis. On admission there was great abdominal distention, evidently due to fluid.

Operation. — An incision was first made as far as the umbilicus, and was extended upward to the xiphoid. The tumor was adherent at the umbilicus. The pedicle was attached to the summit of the bladder. It had no lumen and did not open into

Bryant, T. : Brit, Med. Jour., 1898, i, 1390.

f Carroll, Jane W.: Buffalo Med. Jour., 1895-96, xxxv, 869.

1 Cotte et Delore: Gros kyste de l'ouraque. Lyon med., 1905,, cv, 373.

550 THE UMBILICUS AND ITS DISEASES.

the bladder. The uterus, tubes, and ovaries were normal. The cyst was unilocular and contained between eight and nine liters of brown, hemorrhagic fluid. This was not examined microscopically. The inner lining of the cyst was made up of inflammatory tissue. On the cut surface the urachus was recognized as a cord. The authors say that the cyst had developed from the urachus. The patient made a good recovery.

A Urachal Cyst Simulating an Appendicular Abscess.* — "The patient, aged seventeen and a half years, unmarried, applied to Dr. R. Drummond Maxwell at the out-patient department of the Samaritan Free Hospital on July 16, 1908. She complained of tenderness and swelling in the right iliac fossa, associated with a history of a sudden attack of pain in that region a month previously, and she was admitted into my ward at once. After admission I found that the relations of the swelling to adjacent organs could not well be defined until I examined the patient with the aid of anesthesia, under circumstances presently to be explained. The patient's mother informed me that the catamenia were established at the age of fourteen years, without pain or constitutional disturbance. The periods were always scanty and attended with very little pain, and the interval was about five weeks. The patient had never suffered from any neurosis before, at, or after puberty. On June 16th, one calendar month before admission, the menstrual flow appeared as usual, but was accompanied by violent pain never experienced before. The pain continued for two days and then it abated. The patient at once resumed her work, but the pain returned two days later and obliged her to take to her bed again. During the whole of the week before admission she was quite incapable of attending to her duties. Roughly speaking, as regards what could be made out before anesthesia was employed, there was a fairly defined, almost spheric swelling in the right iliac fossa, slightly movable and tender to the touch. There was resonance on percussion over its outer aspect. The lower part of the swelling could be defined on rectal examination. I refrained from making a vaginal exploration until a consultation was held. Then it was found that the vagina was barely two inches deep. A kind of dimple could be defined at the blind extremity toward the right. The tumor did not bulge into the vagina. At the lower limits of the swelling was a tuberosity which lay behind the vagina and in front of the rectum. The temperature and pulse were low. The patient had never been laid up with any severe illness. Before the arrested development of the vagina had been detected, appendicular abscess was suspected, but after the examination, hematometra or hematosalpinx seemed equally probable. On July 21st the period began, as usual, about five weeks after that which had preceded it. I found that there was no palpable increase of pain or tenderness in the tumor nor any appreciable increase or decrease in size. The flow was unusually free. I decided to examine the patient under anesthesia during the period in order to discover the channel which transmitted the menstrual blood into the vagina, and for other manifest reasons.

"Examination under Anesthesia. — The perineum was markedly deep, so that the anterior commissure lay far forward. The labia, clitoris, and meatus urinarius were normally developed. There appeared, on the other hand, to be Ao hymen nor was there the least trace of carunculse."

"The vagina formed a blind pouch about two inches deep. The rugae were prominent.

Doran, Alban H. G.: The Lancet, 1909, i, 1304.

LARGE URACHAL CYSTS.

551

Ut?

"The vaginal pouch was distinctly deeper on the right side, whence dark menstrual blood was seen to issue. On stretching the adjacent mucosa with the fingers, a crescentic fold with the concavity toward the left was detected. It covered the aperture whence proceeded the blood. A uterine sound could be passed into this aperture and pushed onward for three inches upward, backward, and a little to the right, closely following the outer limits of the lower pole of the swelling, as could easily be defined on digital exploration from the rectum (Fig. 237). On bimanual palpation the swelling was found to be a well-circumscribed tumor, firm, pushed a little downward, yet even then its lower pole did not bulge into the vagina, but passed behind it. The tuberosity in the rectovaginal septum, discovered at the previous examination, lay to the left of the menstruating tract. It felt like a small cervix. The nature of the case remained obscure. I kept the patient at rest for a week. The period ceased, and the tumor remained stationary. There was one sharp attack of local pain on July 28th, without any rise of pulse or temperature."

"Operation. — On July 29th I operated with the assistance of Dr. R. V. G. Monckton, Dr. S. H. Belfrage administering ether and chloroform. I made an incision in the middle line. The parietes were unusually vascular. After separating the recti I came across a thick membrane of doubtful character, and lower clown I exposed the wall of the bladder, which extended for quite two inches above the pubes. The membrane was cut through, and about half a pint of a perfectly clear fluid was removed; unfortunately, none was preserved. The fluid lay in a cyst behind the recti and anterior to the parietal peritoneum, the membrane through which I had made

the incision being the anterior portion of the cyst-wall. The cyst was connected with the bladder by a thick cord half an inch in length. The upper limits of the cyst lay close below the umbilicus. In exploring the upper end of the tumor I laid open the peritoneal cavity. The omentum adhered to the peritoneum, investing the back of the cyst in this region. The intestines seemed healthy; there was no evidence of tuberculous disease, no free fluid, and no intraperitoneal tumor. Lower down some coils of ileum adhered to the parietal peritoneum behind the tumor. "I endeavored to define the relations of the cyst to the genito-urinary tract. A catheter was passed into the bladder, and a few ounces of urine were drawn off. There was no communication between the cavity of the bladder and the cavity of the cyst; the thick cord between the two was clearly a portion of the urachus, and I observed that it ran into and not over the cyst-wall.

"As might have been suspected from what could be defined before the operation, the cyst lay to the right of the middle line. On pressing against its wall on the right interiorly, from the inner side I detected a fusiform body like a uterine cornu or a small but entire virgin uterus, lying in the position of the menstruating tract along

Fig. 237. — Diagram Showing the Arrested Development of the Genital Tract and the Relation of the Malformed Parts to the Cyst of the Urachus. (After A. Doran.) Vg, vagina, its blind end rising higher on the right side than on the left; VI, valvular fold, through which a sound (~~) passes into Rt. Ut., the right cornu; Ov, right ovary; Lft. Ut., solid body, probably left cornu; the dotted lines indicate a band, not clearly definable, connecting it with the right cornu.~~

~~552~~

~~THE UMBILICUS AND ITS DISEASES.~~

7

I

which a sound had been passed a week before. Above this body thickened tissue could be felt — apparently a small ovary. The tuberous, cervix-like body already mentioned could be plainly defined through the walls of the lowest part of the cyst. When thus explored, it was found to be a distinct, fairly movable structure — the left ovary or uterine cornu. On further palpation through the cyst-wall the pelvic cavity felt quite free from any tumor or deposit. There certainly was no such thing as a collection of retained menstrual blood.
" At this stage of the operation it became evident that the swelling, which disappeared entirely when I opened the cavity full of fluid, was a urachal cyst. The swelling — in other words, the cyst — had been the cause of all the patient's recent trouble. As there was no trace of a hematometra or hematosalpinx, I did not feel justified in dissecting in the dark behind the cyst, amid deformed structures, in
very uncertain relations to ureters, blood-vessels, etc., merely to make out the extent of arrested development of the uterus and appendages. It was with the cyst, therefore, alone that I had to deal. I knew of several objections to the draining of a urachal cyst, nor could I dissect away its outer wall, since, as I have just observed, its positive relations to malformed structures were very uncertain. For these reasons I simply trimmed away as much of the lining membrane as could be safely removed. Then I cautiously passed several fine catgut sutures along the substance of the outer wall and tied them, so that the cyst cavity was closed in. This outer wall was the muscular sheath of the urachus abnormally thickened, so that the manceuver just described was easy and nothing was caught up behind the cyst. I transfixed the segment of the urachus, which ran between the lower limits of the cyst and the bladder, with a fine linen suture and tied it on both sides. It was then divided between the cyst and the ligature. As will be explained presently, it is fortunate that I transfixed the urachus instead of tying a single ligature around it as though it were an artery. I kept the portion attached to the cyst for microscopic examination. Lastly, the sheaths of the recti were united with interrupted fine linen sutures and the integuments closed with interrupted silkworm-gut.
"During the summer vacation Dr. Maxwell took charge of the patient in my absence. He reported that up to the day of her discharge at the end of August there was no sign of leakage of urine through the wound nor any show of blood."
Microscopic Examination of the Cord Between the Cyst and the Bladder. — A section of the cord-like structure which ran on the surface of the parietal peritoneum

Fig. 238. — Section of the Segment op Urachus which Passed Between the Bladder and the Cyst-wall, as Seen Under a Low Power. (After A. Doran.) The canal is quite unobstructed and lined with transitional epithelium; the muscular coat is very thick. (In our reproduction part of the detail has been lost — T. S. C.)

LARGE URACHAL CYSTS. 553
between the fundus of the bladder and the cyst was made at the Royal College of Surgeons of England. There could be no doubt that it was a portion of the urachus. Mr. S. G. Shattock reported that the canal was quite patulous and lined with perfect transitional epithelium of the bladder type. The lumen was free from catarrhal or other morbid products. The muscular coat was abnormally thick, but showed no evidence of inflammation or edema. Its inner portion was mostly made up of circular, and its outer portion of longitudinal, fibers, but there was some irregularity in the direction of the fibers in both portions. Some subperitoneal fat was intimately connected with the periphery of the urachus. The appended reproduction of a photomicrograph (Fig. 238) shows the above-described appearance of the urachus as seen under the microscope.
On p. 635 I have recorded another interesting case of Doran's — a cystic sarcoma of the urachus.
A Large Cyst of the Urachus. — Dossekker* reports the case of a woman, born in 1850. When forty years of age a tumor the size of a small fist was found to the right of the uterus. She had various abdominal symptoms, and finally was sent to a sanitarium. When forty-two years of age she was admitted under the care of Kronlein. She looked very pale. The abdomen was markedly distended, as with a pregnancy at the ninth month. There was, in addition, a distention at the umbilical region, with definite fluctuation. The diagnosis made was ovarian cyst, possibly from the right side, with hemorrhage into the cyst, and probably torsion of the pedicle.
Operation. — An incision was made from the umbilicus to the symphysis. As soon as the abdominal walls were cut through the knife entered a cyst cavity. The wall of the cyst was intimately attached to the abdominal wall, and a large quantity of thin, hemorrhagic fluid escaped. This was not sticky and had no odor. It amounted to between three and four liters. The tumor was gradually shelled out, with little or no hemorrhage, and the abdominal cavity proper was not opened. The cyst did not extend into the pelvis, but reached as far as the top of the bladder. At no point was the peritoneum opened. In other words, the large cyst with its contents lay between the abdominal wall and the parietal peritoneum. The patient made a splendid recovery. Examination later showed that the uterus and left ovary were normal. The right ovary could not be outlined.
Dossekker, after discussing the various points of interest, says that on histologic examination the wall was found to consist chiefly of dense connective tissue. The inner surface in most places was without any epithelial lining, but at some points this was intact. It consisted of a high, many-layered, so-called transitional epithelium. The basal nuclei were elongate or oval ; the peripheral were more roundish or flat in form. The epithelium corresponded in character to that of the bladder, and agreed with the description given by Luschka of the epithelium lining the canal of the urachus.
A Cyst of the Urachus. — On page 182 Douglasf describes the case of " Mrs. C, aged thirty-six, married eleven years, but sterile. The family and personal history is good; she has always enjoyed good health, but has never been robust. Menstruation has been scanty and painful, but regular; she has suffered with con
~~Dossekker: Klin. Beitrag zur Lehre von den Urachuscysten. Beitrage z. klin. Chir.,~~
1893, x, 102.
t Douglas, Richard: Trans. Amer. Assoc, of Obstet. and Gynecologists, 1897, x, 177.

554 THE UMBILICUS AND ITS DISEASES.
stipation, but the kidneys have acted freely and normally until recently. About eighteen months ago she observed a swelling in the lower portion of the abdomen, rather more prominent on the right side. The enlargement was soft and painless. It grew slowly and did not materially show until the last four months, within which time its growth has been rapid, chiefly to the right side. She has suffered from backache, some loss of flesh, slight cough, and decided digestive disorders. There has been but little pain or tenderness from the tumor, and no history indicating local peritoneal inflammation. The bladder has been somewhat disturbed, its action frequent, but the urine normal. She now complains more particularly of vomiting after eating and a sense of weight and heaviness in the epigastric region. Of late she has grown nervous and suffers from insomnia."
"Physical Examination. — -The abdomen presented a very peculiar appearance. It was symmetrically distended to about the size of a seven months' pregnancy, the greatest enlargement being on the right side; the veins were not enlarged, the skin was white and anemic-looking. By palpation the irregular swelling could be outlined. The tumor seemed to lie in the lower zone and the right half of the abdomen. It was soft, elastic, fluctuant and compressible. It was not movable; there were no irregularities or bosses upon it ; its surface was smooth; palpation was painless; the abdominal walls did not appear to glide freely over the surface of the tumor. There was dulness upon percussion over the entire tumor, yet that dulness, as was repeatedly remarked during examination, was not the characteristic flatness noted in ovarian cystoma. The dulness was absolute low down, but in the region of the umbilicus and beyond, the note became more resonant. Auscultation negative. Vaginal examination showed the uterus small, retroflexed, and rather low in the pelvis ; vaginal vault encroached upon by an elastic, fluctuant swelling. The weight of the evidence was in favor of the diagnosis of ovarian cystoma. The following peculiarities, however, were remarked upon, and were of such importance in our judgment as to render questionable the nature of the case. The appearance of the abdomen was not such as is usually noted in ovarian cystoma. While, of course, we appreciate that the shape of the abdomen varies greatly, yet in a cyst so distinctly unilocular as this appeared to be, and lying so superficially, one would expect to find the abdomen rising abruptly from the symphysis; that is, the tumor forming a distinct angle with the abdominal plane. In this case the abdomen looked more like one distended by ascitic fluid, rather flat upon the upper surface, and widely bulging upon the right flank. The next peculiar physical sign was the character of the percussion dulness.
" Operation. — An incision was made in the middle line, and in going through the linea alba and transversalis fascia I came upon the red, congested cyst-wall, which I at first thought was the peritoneum inflamed. I now aspirated the cyst and drew off 25 pints of clear fluid. An examination of the collapsed sac soon convinced me that I was not in the peritoneal cavity, and that I was dealing with a cyst of the urachus. Its attachment was not very intimate, and its enucleation was readily accomplished. Only slight hemorrhage attended its separation. As I removed the sac I recognized that I was working entirely outside of the peritoneum. The viscera could be felt through the peritoneum. The sac dipped down into the true pelvis in front of the uterus, depressing and retroflexing it. There was no apparent attachment of the sac of a ligamentous character to the bladder. Indeed, the cyst lay between the peritoneum and the transversalis fascia, with no special attachment

LARGE URACHAL CYSTS. 555
beyond a universal adhesion to all surrounding parts. The area of the peritoneum separated from the parietes extended from about three inches above the umbilicus to the symphysis, and from two inches to the left of the linea alba and through the lumbar and iliac regions of the right side. As there was no bleeding of consequence, we now prepared to close the abdominal wound. It was observed that the peritoneum sank away from the parietes, but thinking that, when the abdominal wound was closed, the force of intra-abdominal pressure would bring it in apposition with the wall, no effort was made to stitch it there. The abdominal wound was closed in the ordinary way. A good compress was applied over the abdomen, and a snuglyfitting bandage adjusted.
" The patient sustained but little shock from the operation and was placed in bed in remarkably good condition. The fluid removed measured 25 pints, was of a pale green color, and a few flocculi were observed in it. I regret to say that it was carelessly thrown away without being submitted to chemical and microscopic tests. The sac was composed of a thin, fibrous material, showing no evidence of muscular structure, and almost transparent; it was removed without tearing.
"The patient was operated upon on June 20th at 1 1 o'clock. Twenty-four hours after the operation the pulse was 136, respiration 30, temperature 99.4° F. She was nauseated and had vomited slightly; there was some epigastric distention; she had slept but little; the bowels had not moved, although active efforts were employed; the kidneys had acted sufficiently, 36 ounces of urine having been voided since the operation. The patient now became very dull, inclined to sleep, was roused only when vomiting; the vomiting was of regurgitant character, without apparent effort; the matter ejected had that ugly green color that we so much dislike to see. Her condition grew rapidly worse, the pulse became more frequent, the temperature reached 102° F. She died at 10 a. m., forty-six hours after operation.
"Autopsy. — The entire detached peritoneum on the right side was gangrenous. There was no hemorrhage, and but very little effusion between the peritoneum and wall. There was a little brown, serous effusion in the peritoneal cavity, no pus nor lymph. Death was due undoubtedly to sapremia. The detached peritoneum was not forced against the abdominal wall, as I had supposed it would be, but hung loosely, leaving quite a space between. This peritoneum was deprived of its nutrition, and had simply died from starvation."
Cysts of the Urachus.* — Ferguson says: " I do not feel, however, as has been stated by Tait, that extraperitoneal tumors in that region are all derived from the urachus. Tait's dictum was based on two cases submitted to operation, both of which resulted in death, in neither of which was there a postmortem examination, and in both of which the reported character of the cystic contents would justify the hypothesis entertained by some that cysts originating in the pelvic region may develop upward and forward in such a manner and way as to separate the peritoneum from the anterior abdominal wall, and thus become extraperitoneal. It is my conviction that I have seen at least one case of that character — one which grew to great dimensions and was cured over twenty-five years ago by excision of some of the anterior portion of the sac, and 'suture puckering' of the opening thus made, with drainage of the remainder, enucleation of the entire sac seeming too large an undertaking.
"In June, 1898, the patient, a man aged about forty-seven years, was brought to
~~Ferguson, E. D.: Phil. Med. Jour., 1899, iii, 830.~~

556 THE UMBILICUS AND ITS DISEASES.
my office by Dr. M. B. Hutton, of Valley Falls, New York. He had lost notably in flesh and strength, though he was not anemic. He was inconvenienced by frequent urination, and complained of considerable pain in the lower portion of the abdomen. Dr. Hutton had satisfied himself that notable abdominal enlargement had been developing lately, which he ascribed to a tumor in the hypogastric region. The first recognition of the tumor was about a month earlier, but the first sense or discomfort was felt in July, 1897, nearly a year before the discovery of the tumor.
"On examination a flat tumor was found extending from the pubes to about two inches above the umbilicus, and from near each anterior superior spine of the ilium to its opposite fellow. The upper border was slightly irregular near the umbilical region, but elsewhere the contour was quite regular. The sense of resistance was that of a very firm, solid tumor, and at no point could fluctuation or diminished hardness be found. There was, however, a sense of nearness of the mass to the surface, which led me to state that it seemed to me to be in the abdominal wall, but its flattened shape and hardness, together with some irregularity of the upper border, led me to conclude that it was probabry a malignant disease of the omentum. Though such a growth as a primary trouble must be exceedingly rare, the shape and hardness led me to that working hypothesis, while the freedom from evidence of bowel involvement, and the yet moderate constitutional effects, led me to advise an exploratory operation, the final decision as to what could and should be done with the mass being left to a consideration of the conditions found on section.
"I heard nothing further of the patient until in July, when his increasing size and discomfort led him to accept my somewhat gloomy, or at least to him unsatisfactory, view of his case, and he decided to submit to an operation. Of course, the absence of renal or other contraindication had been established. The operation was undertaken July 26, 1898, and the first surprise occurred when, on moving the antiseptic dressing after he was under the anesthesia, I found the mass to be then of a globular form. To this was added a great diminution in the sense of resistance and a manifest fluctuation, showing the cystic character of the tumor. This change in the tumor was undoubtedly due to the relaxation produced by the anesthetic in recti muscles of unusual development. My first impression now was that I was dealing with a distended bladder, for the sac evidently extended into the pelvis and seemed more remote than formerly. Having satisfied myself that it was not a distended bladder, I proceeded with the operation until I came to the wall of the cyst just under the deep fascia of the abdominal wall. At this juncture the nature of the case flashed upon me, and I was able to state to those present that we were dealing with a cyst of the urachus. This conclusion was strengthened by the water-like appearance of the fluid which was removed by an exploring syringe. It being apparent that the lower portion of the cyst extended deeply into the pelvis and was probably intimately associated with the bladder-wall, a condition that would explain the frequent urination, I exposed the wall of the cyst before opening it, from as near the umbilicus as the mergence of structures would allow, to near the pubes. This I did in order to further a plan which I had quickly formed for the management of the case. In the first place, I had determined not to try to finieleate the entire cyst, bu1 to remove the posterior portion with the underlying peritoneum so far as I could, and allow the reclosure of the peritoneum, dealing with the remainder according to circumstances. Such a procedure would require free access to the deep portions of the cyst, hence my long incision. The cyst was

LARGE URACHAL CYSTS. 557
then opened the entire extent of the overlying incision, and an unknown quantity of water-like fluid escaped. The quantity, from absence of convenience for collection (the operation occurring in a private house), could only be estimated, but it was evidently more than two quarts, and probably less than four quarts.
"It was now practicable to investigate the relation of the wall of the cyst to contiguous parts; it was found to be intimately related to the bladder over a considerable extent of the surface of that organ, for it extended deeply into the pelvis. The posterior wall of the cyst was free from evidence of adhesion or other connection with the abdominal organs, and I was about to excise that portion of the sac when it occurred to me to ascertain whether the inner and secreting layer could be removed, thereby securing a surface which would unite. Beginning at the inner edge of my incision in the wall of the sac, and near the lower end of the opening of the belly, I was surprised and gratified to find that a layer of tissue, so thin as to be diaphanous in moderate light, and so strong as to allow of considerable traction without tearing, could be removed without much trouble and with practically no hemorrhage. In that manner the entire lining of the cyst was removed except at the umbilical region, where quite a surface existed, in which digitations penetrated the abdominal wall, and a blending of the tissues prevented the removal of the lining. This surface seemed rather large for complete excision with subsequent easy closure of the belly at that point, hence it was allowed to remain while attention was given to the denuded portion of the cyst. A single deep skin suture was placed to divide the unclosed umbilical area from the subcutaneous suturing below that point. Some iodoform gauze was then placed in the pocket left at the umbilicus, where the lining layer could not be removed, and the whole was sealed with a collodion seal, except over the gauze packing, with the request that it be left for several days unless indications arose showing inflammatory processes.
"It had closed in September, and the area showed in December a perfectly normal state of affairs aside from the scar at the umbilicus."
Cyst of the Urachus.* — The patient from whom this specimen was obtained was admitted to the Cook County Hospital February 27, 1895. He was a man fifty-two years of age, white, and single. He was admitted for an illness which had begun four weeks previously, with frequent micturition and pain in the region of the kidneys. Examination revealed an enlarged prostate. He had symptoms of cystitis with retention of urine. Hydronephrosis was present, and uremia ensued. He died on April 9th.
Autopsy Abstract. — " The bladder is large, with markedly thickened walls. Each lateral lobe of the prostate is the size of an English walnut. At the summit of the bladder, and separated from the bladder cavity by a thin membrane, is a cyst, the size of an average orange. It contains a thick, turbid, viscid, brownish fluid. The lining of the cyst presents an irregular surface, but there are no distinct rugae. The irregularities of the cyst lining are present on the upper surface of the interveningseptum, between it and the bladder cavity. The rugae of the bladder are continued upon its inferior surface. The ureters are dilated, as are also the pelves of both kidneys. Careful dissection fails to reveal further urachus remains in the abdominal wall or about the navel. Microscopic examination of the septum between cyst and bladder cavities disclosed the fact that the muscular coats of the bladder-wall were
~~Le Count, E. R.: Transactions of the Chicago Pathological Society, Dec, 1895, to April,~~
1897, ii, 215.

558

THE UMBILICUS AXD ITS DISEASES.

not continued into the septum. This fact, taken in conjunction with the position of the cyst and the fact that the peritoneum of the abdominal wall was reflected upon the back of the cyst, and thence upon the back of the bladder, leaves no doubt that the cyst represents the obliterated and dilated lower end of the urachus."
An Enormous Cyst of the Urachus.* — - The following case is cited on account of some unusual features, and because it should be added to the list reviewed by W. R. Weiser in a most interesting and instructive article published in the Annals of Surgery for October. 1906.
Miss . aged forty. History of slowly growing abdominal tumor, beginning
in the region of the bladder and growing upward, with gradual onset of pressure symptoms, especially difficult respiration, pain, and impaired digestion. The abdomen was enormously distended, but not tender, nor did it bulge much in the flanks. It was rather firm, and was flat on percussion from the pubes to the ensifonn cartilage. Its appearance is well shown in Fig. 239.

Fig. 239. — The Abdominal Contour in a Case of Vest Large D

After T. L. Macdonald.)

"Operation (October 6. 1907). — Through the usual incision the cyst-wall was perforated and the fluid drawn off. Two-thirds came away clear: the remainder was turbid, and. lastly, thick, cheesy masses were wiped out. Investigation of the inside of the sac disclosed several thick, nodular masses which were strikingly carcinomatous in character. So far. the peritoneal cavity had not been opened, the sac being situated in front of it. The task of separating the cyst-wall from the peritoneum and viscera was begun by first stripping and cutting it from the epigastric region and from beneath the ribs, and here the peritoneal cavity was opened. It was hoped that from this point downward the dissection would be less difficult, but it was more so. The anterior surface of the peritoneum seemed to be fused with the sac, and the posterior with the viscera generally: and the character of the adhesions was the most dense ever encountered by the writer. These were followed deeply into the pelvis, in all directions, and freed: and finally the firm, fibrous
~~Macdonald, T. L.: Ann. Surg:.. July-December, 1907, xlvi. 230.~~

LARGE URACHAL CYSTS.

559

attachment to the bladder was severed and the sac removed. The appendix, six inches in length, bright red, and surrounded by adhesions, was also removed. The abdomen now presented a most unusual sight. With the exception of the anterior surface of the stomach, not a vestige of normal peritoneum was visible. All the abdominal contents, including tubes, ovaries, uterus, and bladder, could be seen outlined through the thin, raw film of peritoneum to which they were firmly attached. The abdominal cavity was filled with normal salt solution and closed with three layers of buried absorbable sutures without drainage.
"Fig. 240 shows some of the nodular masses. There are others on the opposite side. These were on the inner surface of the sac, which was photographed in this way. The cyst was turned inside out, and through the incision, which had served for the evacuation of the contents, a large, thin, collapsed rubber punching bag was thrust, then inflated, thus distending the sac for photographic purposes.
"The report of our hospital pathologist, Dr. Birdsall, shows the cyst-wall to be fibrous, and the nodular masses, which, during operation we feared were carcinomatous, were papillomata. Of course, in a cyst of this size, which had been growing presumably for forty years, and subjected to the ever-increasing pressure of the accumulating fluid, we could not expect to find the normal histologic features of the urachus. Naturally, all except the fibrous structures would disappear by pressure absorption ; even bone has been known to do the same.
"Postoperative Course. — The patient's condition was critical for the two following days, active stimulation and intravenous saline infusion being demanded. The wound healed by primary union. The bowels were loose. The temperature ranged from 101° to 102° F. Daily palpation of the abdomen revealed fluctuation, and the percussion-note
was flat, showing that the salt solution was not being absorbed. On the seventh day a chill occurred, followed by a rise in temperature to 104° F. Assuming that the unabsorbed solution had become infected through the raw surface of the intestines, the lower end of the now healed wound was cocainized and cut through, allowing the escape of quarts of the salt solution, which had become purulent, and which presented the colon bacillus characteristics. This was followed by prompt improvement. Drainage and irrigation were continued for a week, after which the wound closed and convalescence and return to health were satisfactory.
"Comments. — The density of the adhesions cannot be appreciated unless encountered. It is true, incision, evacuation, and drainage would probably have been successful after a long period of waiting for the cavity to undergo obliteration. The assumption, however, that portions of the sac had become carcinomatous made extirpation seem imperative.
"Extirpation is evidently not commonly resorted to. Among the 86 cases re

Fig. 240. — A Urachal Cyst Turned Inside Oct and Showing Papillary Masses, Particularly in the Lower Part of the Picture. (After T. L. Macdonald.)

560 THE UMBILICUS AXD ITS DISEASES.
viewed by Dr. Weisef, only eight were extirpated. Xone of these was said to be large, and with one or more the history and result were lacking."
Dilated Urachus Treated by Incision and Drainage.* -The patient. W. J. P.. was a man aged fifty-four who consulted Dr. Pratt on June 8. 1889. complaining of pain and distention in the abdomen and increasing general weakness. He had been quite well until the previous November, when he complained of pain in the lower part of the abdomen. He remained in bed for three weeks and in the house for four months. He could not account for the onset of the trouble in any way. There had been no blow, no lifting of heavy weights, nor straining of any kind. His occupation was that of a store-keeper and clerk near Xew York, where he had lived for many years. He had had a gonorrheal infection when twenty-one. but had never had symptoms of syphilis. He had led a very intemperate life until seven or eight years previously. Since then he had been a moderate drinker. On examination the abdomen was found to be much distended in the lower half and in front : the distended area was dull on percussion and reached as high as three fmgerbreadths above the umbilicus. The pain extended as far as the pubes. laterally, on either side, as far as vertical lines drawn through the anterior superior iliac spines. He had no trouble with micturition or defecation. The urine appeared to be normal. The prostate was not enlarged, but there was a fulness of the left side of the pelvis.
On June 15. 1889. the tumor was aspirated and about one dram of a gummy, semitransparent fluid, which blocked the tube was withdrawn. It contained only a trace of albumin, but a large quantity of mucin, as shown by the precipitate it gave with acetic acid. Microscopically it showed many leukocytes.
On July 9th Mr. Bond made a four-inch median incision midway between the umbilicus and the pubes. After division of the linea alba a very thick membrane was reached, resembling a peritoneum much thickened by tubercular peritonitis. It proved, however, to be the outer wall of the cyst. It was divided, and a very large quantity of a ropy, gummy, semisolid material came away, of which over a gallon was measured. This had the appearance and consistence of semi-decolorized fibrin, was partly squeezed and partly drawn out in stringy layers. A considerable quantity was left in the cavity, as any attempt to sponge it off the inner surface of the cyst-wall left a red. raw surface which bled freely. On exploration of the cavity with the hand and arm it was found to extend upward to and beneath the liver and downward into the pelvis. The intestines could be made out behind and at the sides of the cyst, though shut off and separated from it. The peritoneal cavity was not opened. A Keith drainage-tube was placed in the wound, and reached to the floor of the pelvis. The rest of the incision was closed.
Chemical examination showed that there was only a trace of albumin, that the fluid was practically mucus and fibrin, with a large predominance of the former. Microscopic examination showed mucus-corpuscles and blood.
The cyst-walls shrank, and the patient gradually improved. In December 1889, on his departure for America, he seemed to be in good health, could walk nine miles at a stretch, and his appetite was excellent. There still remained, however, an irregular shaped cavity with thickened walls capable of holding half a pint of fluid. Mucoid material was secreted daily. The discharge, however, was not fetid and did not seem to in any way depress his health. In a letter dated February
~~Pratt. R.. and Bond. C. J.: The Lancet. 1890, i, 898.~~

LARGE URACHAL CYSTS. 561
27, 1890, the patient said that the wound was still kept open by a glass tube, and that there was a discharge of clear, watery fluid, with very little of the jelly-like material. The man was in excellent health and was working thirteen hours a day.
A True Urachal Cyst. — Von Recklinghausen* demonstrated a cyst, about the size of a walnut, which had been removed from a man thirty years of age. The cyst varied from 1 to 3 cm. in diameter, and contained tenacious, colorless mucus. It was situated directly at the top of the bladder, with which it was intimately connected. It lay in the median line in the subperitoneal adipose tissue, and was completely cut off from the bladder. It was polycystic. There was a main cavity with many bays running off from it, and in addition to this there was a small cystic mass which was attached to the bladder, and which contained a labyrinth of microscopic spaces looking like gland loops, or, at any rate, like dilated crypts. The dense connective-tissue walls were nearly everywhere covered over with bundles of smooth muscle-fibers. The epithelium was several (or usually two) layers in thickness, and was definitely squamous in type. Here and there in the crypts were abundant numbers of goblet-cells. On account of the presence of goblet-cells it was necessary to consider the possibility of an enterocystoma; in other words, a derivative from the omphalomesenteric duct. But von Recklinghausen said that this could be excluded, because the tumor was entirely extraperitoneal and because it was in no way connected with the peritoneum.
Cyst of the Urachus. — Reedf cites a case (his Fig. 321) in which the sac had extended from near the ensif orm cartilage to the pubes and forced the viscera from their normal positions. The cyst was enucleated without any opening into the peritoneal cavity. He gives a schematic picture of the condition. Microscopic details are lacking.
Probably a Urachal Cyst.t — This case was also reported by Freer. A divinity student had from infancy been remarkable for his large abdomen, which had made him an object of ridicule to his companions. Thinking adipose tissue to be the cause, he had tried to reduce it by fasting, but without avail. It caused him no trouble until his twenty-fourth year, when a marked increase in size took place. This seriously impeded his respiration and led to an examination, which revealed fluctuation in and around the umbilical region. The dyspnea having increased to such a degree that relief became imperative, a puncture was made and a considerable. quantity of reddish-yellow fluid escaped. The procedure was followed by vomiting and intense abdominal pain. The puncture afforded him some relief, and with the exception of occasional fainting spells, his health remained good for a period of two years, after which his abdomen again commenced to increase in size, the dyspnea returned, and his general appearance became cachectic. He again entered the hospital and six liters of bloody fluid were withdrawn. The operation was repeated three times during the ensuing nine months — the remainder of his life. The amounts of fluid were 18^, 17, and 6 liters respectively. At his death he weighed about 192 pounds. At autopsy the contents of the cyst were found to amount to 50 liters, which weighed about 100 pounds. The cyst fluid contained
~~Von Recklinghausen: Eine richtige TJrachuscyste. Deutsche med. Wochenschr., 1902,~~
xxviii, Vereinsbeilage, 266.
t Reed, Charles A. L.: A Text-Book of Gynecology, 1901, 805.
i Rippmann, G. : Eine serose Cyste in der Bauchhohle, mit einem Inhalt von 50 Liter Fliissigkeit. Deutsche Klinik, 1870, xxii, 267. 37

562 THE UMBILICUS AND ITS DISEASES.
cholesterin crystals, flat epithelium, and fat-droplets. A minute examination of the cyst-wall showed it to consist of three layers, the external being a serous coat. This rested on a layer composed of elastic and fibrous tissue, and the interior was lined with pavement epithelium. The bladder contained a little yellowish urine. It was contracted, and its lining mucous membrane was pale. The urachus was found closed at the bladder end. In its course toward the umbilicus below the commencement of the large cyst, a small cyst was situated near the umbilicus. The fibrous tissue passed into the subperitoneal coat of the larger cyst, which occupied almost the whole abdominal cavity, but the cyst was absolutely independent of the abdominal cavity and the abdominal organs were normal.
Probably a Urachal Cyst. — Schaad's* patient was a married woman thirty-two years of age. Nothing was known about the condition of the umbilicus at birth. She had had two normal labors. At the last labor a tumor had been noted below the umbilicus. The patient was supposed to have had a severe inflammation of the bowels seven years before. Several fingerbreadths below the umbilicus could be felt an elastic tumor the size of a child's head. It could be sharply outlined and pushed in all directions.
A cyst the size of a five-franc piece was found situated about two fingerbreadths below the umbilicus, and attached to the abdominal wall in the mid-line. It was separated from the peritoneum and drawn out of the abdomen. The omentum was tied off; the cyst was found adherent to the appendix. The left ovary was hard and atrophic; the right ovary was normal. The patient recovered.
The cyst was oval in form, and measured 7.5 x 6 x 4.5 cm. The walls varied from 2 to 4 mm. in thickness. The outer surface was fairly smooth, except where it was adherent. The inner surface resembled mucosa and was light yellow in color, with dark spots. On the right side of the cyst was a secondary cyst opening into the larger one. The opening was the size of a pin-head. The inner surface of this second cyst was smooth and yellow; its walls were 1 mm. thick. The large cyst contained about 200 c.c. of a chocolate-colored, cloudy, tenacious fluid, showing much cholesterin, detritus, fat-droplets, etc. The contents of the small cyst were similar in character, but thicker. The wall of the large cyst consisted of connective tissue and large quantities of smooth muscle arranged in bundles. These ran in all directions. The inner surface was lined with high cylindric epithelium; there were also glands opening upon the surface. In places the epithelium and glands were absent. The small cyst was lined with granulation tissue, in which were encountered giant-cells, some containing as many as 20 or 30 nuclei, arranged at the margin or irregularly scattered or in the center. [These are suggestive of foreign-body giant-cells.] Schaad felt sure that he was dealing with an omphalomesenteric duct, a portion of which had remained open, with a resulting retention cyst. [From the cases followed in the literature the case strongly suggests a urachal cyst. The question, however, is an open one. — T. S. C]
A C y s t i c Urachus. — Scholzf reports the case of a sixteen-year-old girl who complained of difficulty in micturition and a painful tumor in the abdomen. The abdomen was prominent, the largest measurement being between the umbilicus and symphysis. The tumor was very painful. On both sides there was tympany.
~~Schaad, T.: Ueber die Exstirpation einer Cyste des Dotterganges. Correspondenzbl.~~
f. Schweizer Aerate, 1886, xvi, 345.
fScholz: Wien. med. Wbchenschr., 187S, xxviii, 1327.

LARGE URACHAL CYSTS. 563
After a time an opening, about the size of a hair, developed at the umbilicus, and fluid escaped from it. The opening was dilated and about 300 c.c. of colorless, transparent, thick, tenacious fluid escaped, and finally a thick yellow pus. The wound closed in the course of two months.
A Large Urachal Cyst.* — Case 1. — "This case was sent to me by Dr. Lamb, of Albrighton. She had complained of abdominal pain and tenderness, and in October, 1880, she began to suffer from somewhat serious symptoms, more particularly frequent vomiting and disinclination to take solid food. Some swelling in the lower part of the abdomen was noticed about the same time, this being then regarded as ascitic. The symptoms slowly increased in severity until February 11, 1881, when a consultation was held between Drs. Lamb, Heslop, and Saundby. As a result of this consultation she was tapped, and 10 pints of fluid were removed, although this was by no means the amount of fluid in the cavity, because large masses of flocculi obstructed the tube of the trocar and prevented the complete emptying of the cyst. Some of this fluid was submitted to me for an opinion, and from the fact that it was brown and thick and gave an abundant flaky yellow deposit, which consisted chiefly of pus, I unhesitatingly gave the opinion that it was not ascitic, but a fluid that must have been contained in some cyst cavit3 T , probably a cyst of the parovarium. I saw her on February 13th, when we found that the abdomen was quite as much distended as before the tapping. I therefore proposed an exploratory incision for the removal of the tumor, if it were possible to remove it, although the extremely exhausted condition of the patient gave no very great prospect of success. It was perfectly clear, however, that if let alone nothing but death could be the result, and therefore an operation was accepted by her attendants and relatives.
" I opened the abdomen at the usual site, and after cutting through all the layers except the peritoneum I came upon the cyst-wall. I opened the cyst and removed about 30 pints of fluid, exactly the same as that which had been removed at the tapping; and mixed up with it I found large masses of the fibrinous deposit, which accounted for the failure of the tapping to remove the whole of the fluid. I then proceeded to remove the enormous cyst, which was uniformly attached to the parietal wall on its outer aspect, and to the outer surface of the thickened peritoneum on its posterior aspect. The cyst did not dip into the pelvis at all, and the anterior parietal peritoneum did not reach the wall lower than the ensiform cartilage. The intestines and the pelvic organs could be felt through the anterior peritoneal fold, non-adherent, and, as far as could be determined, perfectly healthy. The cyst lay, therefore, entirely between the transversalis fascia on the outer side and the parietal peritoneum on the inner, the peritoneal cavity having been nowhere opened during the severe and protracted operation. The cyst was removed in its entirety, and its inner surface consisted of broken-down mucoid epithelium, infiltrated everywhere with pus, lying upon the basement membrane, wmich consisted almost entirely of muscular fibers.
"The conclusion concerning the nature of this cyst, at which I have arrived, is that it was developed from the urachus, a part of which had been occluded at both ends, but during the developmental changes of embryonic and infantile existence had not become obliterated. I entirely fail to see any other possible origin for it, and, if my explanation be correct, it is very marvelous that this structure should have re
~~Tait, Lawson: Twelve Cases of Extraperitoneal Cysts. Brit. Gyn. Jour., 1886-87, ii, 32S.~~

564 THE UMBILICUS AND ITS DISEASES.
mained quiescent for fifty-six years and then should suddenly undergo an inflammatory change which developed it into this enormous cyst. The patient went on very well for three days, and then rapidly sank from exhaustion. No postmortem examination was allowed, and therefore I can shed no further light upon it; and, as far as I know, the observation is unique, although it is perfectly well known, as I myself have repeatedly had occasion to observe, that small cysts of the urachus are opened in abdominal section. I do not know that any such cyst has previously been met with sufficiently large to be of pathologic importance. It was noted and published at the time that the basement membrane of this cyst consisted almost entirely of muscular fiber, an observation which is absolutely concurrent with the examination of the cyst in Case X, made by Mr. Bland-Sutton."
Probably a Large Urachal Cyst.* — Case XI. — -"This case was sent to me by Dr. T. S. Bourne, of Kenilworth, as a case of acute inflammatory disease of the abdomen, of which he said: "I find it impossible to make an exact diagnosis." When I saw her I found her with a high pulse and temperature, and abdomen distended with a large quantity of free fluid. My opinion, expressed at the time, was that it was a case of tubercular peritonitis. I made the usual section, and found it another of these cases of congenital cysts belonging to the category of the cases already described in numbers IV, V, VI, VII, VIII, IX, and X. I removed a small piece of the cyst-wall for examination, and the reports of the microscopic examination by Dr. Arthur Johnstone and Mr. J. Bland-Sutton of Cases X and XI are annexed. I used the circular drainage method, and the patient has completely recovered. The following is Mr. Bland-Sutton's report:
"Sections of the cyst-wall exhibited under the microscope a mixture of fibrous and non-striated muscle tissue arranged in fasciculi, closely corresponding to the disposition of the bundles of tissue which make up the walls of the urinary bladderScattered throughout the whole thickness of the sections were small calcareous nodules. It was difficult to make out any definite epithelial investment to the sections, but on scraping the smooth surface of the specimen with a cover-glass, the field of the microscope became crowded with flattened, rounded, and pyriform cells, similar to those found lining the interior of the urinary bladder, only very much smaller.
"As the urachus is lined with epithelium agreeing in shape, and continuous with that found in the interior of the bladder, the evidence that these cysts are allantoic seems to me to be complete (J. Blancl-Sutton)."
[Tait cites a considerable amount of literature and discusses other cases at length. It is very difficult to tell in the majority of these cases whether he was right in his assumption or not. His entire paper, however, is a very interesting one.— T. S. C]
A Urachal Cyst. — Wolff | reports two cases which came under his observation in the clinic in Marburg in 1872, and which, according to his view, were urachal cysts. I shall here report only Wolff's Case I.
Mrs. K., aged thirty-one, was always healthy in childhood. Two years before her admission she noticed a tumor in the left side of the lower abdomen. This gradually increased. In March, 1872, there was a pregnancy which terminated nor
~~Tait, Lawson: Loc. cit., Case xi.~~
f Wolff, C. C: Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873.

LARGE URACHAL CYSTS. 565
mally, but was followed by an acute fever, with severe pain in the left part of the abdomen. The abdomen suddenly reached enormous proportions in a few days. The patient was treated by her physician for peritonitis. Convalescence was slow, but the patient again became quite strong. On palpation of the abdomen, a tense, elastic, fluctuant, rounded tumor could be felt. This filled the entire left side of the lower abdomen, and extended over to the right a handbreadth beyond the linea alba. Upward it reached beyond the umbilicus. The tumor could not be pushed from side to side. It had a smooth surface, and apparently consisted of one mass. A median incision was made, but the peritoneum did not become visible. After careful dissection the cyst was opened and yellowish, serum-like fluid escaped. The patient was laid on her side and the contents of the cyst gradually flowed out. After 5 liters of fluid had been removed in this way, the tumor was gradually loosened. The peritoneum was thickened, evidently as a result of inflammation. In the inner part of the cyst were large, lumpy coagula of fibrin. The connection of the cyst with the peritoneum was in part firm and in part very loose. The tumor was shelled out without difficulty. It was possible to do the operation almo.st entirely extraperitoneally; only at one point was the peritoneum opened for a distance of 1 cm. This was closed with silk. The patient made a good recovery.
The cyst was egg-shaped. Its largest circumference was 63 cm. When flattened out it was 31 cm. in breadth. The cyst-walls varied from 1 to 3 or 4 mm. in thickness. The outer surface was rough, with numerous string-like processes which indicated where the adhesions to the peritoneum had been cut. It had a poor blood-supply. The cyst-wall had a tough consistence. The interior of the cyst was smooth, like a serous wall. It had over its surface fibrinous deposits. According to Lieberkuhn, who made the histologic examination, the cyst-wall consisted of fine connective tissue with fibers running in various directions; here and there were non-striated muscle-fibers. A definite epithelium was not detected on the inner surface. The fluid consisted of large granular masses of detritus and pus-cells.

LITERATURE CONSULTED ON LARGE NON-INFECTED URACHAL CYSTS. Atlee, W. L.: Ovarian Tumors, Lippincott, Philadelphia, 1873, 50. Baldwin: Large Cyst of the Urachus. Surg., Gyn., and Obst., 1912, xiv, 636. Bantock: See Tait's article.
Bryant, T.: Discussion on Doran's paper, Brit. Med. Jour., 1898, i, 1390. Carroll, J. W.: Cystic Urachus. Buffalo Med. Jour., 1895-96, xxxv, 869. Cotte et Delore: Gros kyste de l'ouraque. Lyon med., 1905, cv, 373. Doran, A. H. G.: Urachal Cyst Simulating Appendicular Abscess; Arrested Development of
Genital Tract; with Notes on Recently Reported Cases of Urachal Cysts. The Lancet,
1909, i, 1304. Dossekker: Klin. Beitr. z. Lehre von den Urachuscysten. Beitrage z. klin. Chir., 1893, x, 102. Douglas, R.: Cysts of the Urachus. Trans. Amer. Assoc, of Obstet. and Gynecologists, 1897,
x, 177. Ferguson, E. D.: Cysts of the Urachus. Phila. Med. Jour., 1899, hi, 830. Ill, E. J.: Tumors of the Urachus. Trans. Amer. Assoc, of Obstet. and Gynecologists, 1892, v,
238.— Amer. Jour. Obstr., 1897, xxxvi, 568. Le Count, E. R. : Cyst of Urachus. Trans. Chicago Path. Soc, Dec, 1895, to April, 1897, ii, 215. Macdonald, T. L.: An Enormous Cyst of the Urachus. Annals of Surg., July-December, 1907,
xlvi, 230. Pratt and Bond: Dilated Urachus Treated by Incision and Drainage. The Lancet, 1890, i,

566 THE UMBILICUS AND ITS DISEASES.
Von Recklinghausen: Eine richtige Urachuscyste. Deutsche med. Wochenschr., 1902, xxviii,
Vereinsbeilage, 266. Reed, C. A. L. : Cyst of the Urachus. A Text-Book of Gynecology, 1901, 805. Rippmann, G.: Eine serose Cyste in der Bauchhohle, mit einem Inhalt von 50 Liter Fliissigkeit.
Deutsche Klinik, 1870, xxii, 267. Schaad, T.: Ueber die Exstirpation einer Cyste des Dotterganges. Correspondenzbl. f. Schweizer
Aerzte, 1S86, xvi, 345. Scholz: Cystis urachi. Bericht des k. k. Allg. Krankenhauses, Wien, 1877 (quoted by Wutz) . Tait, L.: Twelve Cases of Extraperitoneal Cysts. Brit. Gyn. Jour., 1886-87, ii, 328. Weiser, W. R.: Cysts of the Urachus. Annals of Surg., 1908, xliv, 529. Wolff, C. G: Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873. Wutz, J. B.: Ueber Urachus und Urachuscysten. Virchows Arch., 1883, xcii, 387.

~~Chapter XXXIII. Abscesses in the Anterior Abdominal Wall between the Umbilicus and Symphysis due to Infection of Urachal Remains or of Urachal Cysts~~
Report of a personal observation. Clinical course. Treatment.
Cases of abscess of the abdominal wall due to infection of remains of the urachus, and not communicating with the bladder.
My attention was particularly drawn to this group of cases in 1910 when Dr. L. Gibbons Smart, of Lutherville, Md., askecl me to see a boy, aged fifteen, who was complaining of a hard mass extending from the symphysis to the umbilicus in the mid-line. There was no history of abdominal injury.
Seven weeks before, the patient had begun to suffer with severe pain in the lower abdomen. On making an examination he had noted that it was very hard to the touch, but not tender. His pain had been constant during one day, and then had disappeared, only to recur every few days and last a day or two at a time. Sometimes the pain in the mid-line had disappeared; on other occasions it had been referred to the right or left side. He did not remember having had chills or fever until two weeks before entering the hospital, when he had had a chill, followed by an elevation of temperature. After this there had been several chills.
He had had no increased pain when voiding and had never passed any urine from the umbilicus, nor had he any umbilical discharge. He said he remembered having had a few night-sweats.
His appetite for the last eight weeks had been very poor, following a period of several months when he seemed unable to satisfy his craving for food.
The patient was a well-developed and healthy looking youth. He said that at the time he first noticed the condition his abdomen was just as hard as it was on the day that he entered the hospital, seven weeks later. His bowels were usually constipated ; his urine was normal.
Operation. — Church Home and Infirmary, June 11, 1910. Under anesthesia it was noted that the umbilicus was more prominent than usual, and that it welled out on both sides (Fig. 241) . The hardness in the abdominal wall also became much more evident when the patient was asleep. I made an incision commencing just below the umbilicus and extending to the symphysis. After separating the recti we found that the tumor lay extraperitoneally. It was exceedingly hard, and almost as dense as cartilage. An incision having been carefully made through this hard tissue, we encountered a sac, somewhat irregular in form, and filled with brownish, grumous contents amounting to about 50 c.c. The cavity was carefully scraped out. A portion of the thickened wall was removed for examination, and the cavity packed with iodoform gauze. The patient made a complete recovery.
Histologic examination of the tissue showed newly formed connective tissue, but without any evidence of an epithelial lining.
567

568

THE UMBILICUS AND ITS DISEASES.

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Fig. 241. — Infected Urachal Remains. The umbilicus is prominent and wells out. The recti muscles have been retracted, exposing a hard, indurated mass. Its walls were exceedingly dense, in places fully 2 cm. thick, and as hard as gristle. The cavity was irregular i r. i. iii line and contained about 50 c.c. of brownish, grumous contents. On histologic examination the walls of the mass were found to be composed of dense fibrous tissue and the cavity was lined with granulation tissue. No attempt was made to remove the mass. The cavity was wiped out and packed, and in a few weeks the mass had literally melted away, leaving a perfectly soft abdominal wall. The patient at the present time (March 1, 1916) is perfectly well.

URACHAL INFECTIONS. 569
The patient has since remained absolutely well. In this case the situation of the tumor left little or no doubt that we were dealing with remains of the urachus which had undergone a low grade of infection. The rapidity with which the inflammatory tissue literally melted away after drainage was established was remarkable.
CLINICAL COURSE.
One of the first symptoms is a feeling of pain or discomfort in the lower abdomen. As the process advances, the pain may be intermittent in character, as noted in my case, or sudden and violent, as experienced in Page's case. Arrou's patient, a soldier, had such abdominal discomfort that, when on the march, he walked with his body bent forward. Vaussy's patient experienced great abdominal pain, which was intensified on inspiration.
A moderate degree of fever was noted in Arrou's, Page's, Vaussy's cases, and in Weiser's Case I. My patient also had some fever and also night-sweats.
As often happens when pus is forming, some patients had a loss of appetite. Page's patient -was nauseated, and Baldwin's suffered a good deal from vomiting. Page's patient had diarrhea, and in Hornig's case there was loss of weight. Vaussy's . patient was markedly depressed. In those cases in which the posterior surface of the abscess causes an inflammation of the peritoneum the constitutional symptoms will be more marked.
From Weiser's Case II we get a graphic picture of the alarming symptoms that may develop: "On admission her temperature was 101.2° F., pulse 172, respirations, 30. The child was pale and emaciated, and had a dry tongue and an anxious expression. She complained bitterly of abdominal pain, and the entire abdomen was tender, especially so about the umbilicus, and the entire abdomen was greatly distended and board-like. A positive diagnosis was not made prior to operation, but tubercular peritonitis and suppurative urachal cyst were both considered."
There are, as a rule, no bladder symptoms. In Van Hook's sixmonths-old patient, however, the urine was quite turbid. In Weiser's seventyfive-year-old woman there had been frequent micturition for a month prior to operation. This absence of vesical symptoms stands out in sharp contrast to what occurs in those cases in which the urachal enlargements have a direct connection with the bladder. In the latter, vesical symptoms are the rule.
On examination of the abdomen it is often possible to detect a board -like induration between the umbilicus and symphysis. If the abdominal walls are particularly lax, one may be able to grasp the tumor in the hand and move it from side to side. As a rule, however, this is possible only when the patient is asleep and the recti muscles are relaxed.
As a rule, the abdominal skin looks perfectly normal. In Van Hook's case, however, the umbilicus had a red, inflamed appearance, and thin pus trickled from a small opening in the lower umbilical fold when pressure was made on the tumor. The right inguinal glands were enlarged.
In Weiser's Case II the umbilicus was surrounded by a zone of redness, where the abscess was ulcerating toward the surface. In Weiser's seventy-five-year-old woman there was a copious discharge of pus from the umbilicus, which had existed for fifteen years.

570

THE UMBILICUS AND ITS DISEASES.

Although the abscess usually opens at the weakest point, viz., the umbilicus, nevertheless, in rare instances, a fistulous opening may develop in the mid-line between the umbilicus and bladder, as indicated in Fig. 242.
The Abscess Sac. — The abscess walls are usually densely adherent to the recti in front and to the peritoneum behind. They vary much in thickness, some reaching in places almost 2 cm. The inner surface of the sac is usually smooth and velvety, resembling an ordinary abscess sac. The contents of the sac vary considerably. Sometimes they consist of ordinary pus; this, in Vaussy's case and also in Weiser's seventy-five-year-old woman, was very fetid. The fluid
may, however, be yellowish red, yellowish brown, or brownish in color, and be grumous or ropy in character and contain necrotic material, which Baldwin and Doran said reminded them of "disintegrating omentum."
From a careful consideration of these cases it seems to me that yellowish or brownish contents are found in those in which a very low and slumbering grade of infection has existed, the typical pus being found in the more acute inflammations.
In Arrou's case a calculus the size of an olive was found in the sac. It looked like a piece of incompletely dried mortar.
Weiser's seventy - five - year - old woman had in the abscess sac a calculus that weighed 70 grains. As noted from his personal communication to me, it was hard, had a dark-brown surface, and on section resembled a bladderstone in color and appearance.
On histologic examination the walls of the sac are found composed in a large measure of dense inflammatory tissue. In places some non-striped muscle may still be detected; all trace of transitional epithelium is usually lost, but it may occasionally be recognized in the contents of the abscess. For abscesses developing in the subumbilical space the reader is referred to the investigations of Fischer, given in detail on p. 263.

Fig. 242. — A>r Infected Urachus Opening Between the Umbilicus and Bladder. (Schematic.) When a urachal infection opens, it is usually either at the umbilicus or bladder; occasionally, however, it perforates the abdominal wall below the umbilicus, as indicated here.

TREATMENT. After the median abdominal incision has been made and the recti have been separated, the abscess wall is at once encountered. If the walls are thin, the cavity is readily reached, but at times it is necessary to cut deliberately through from 1 to

URACHAL INFECTIONS. 571
2 cm. of very dense tissue before the fluid is readied. The cavity should be wiped out, and, if it has thick walls, it should be curetted. It is then packed with gauze and allowed to close by granulation. Great care should be taken to avoid opening the peritoneal cavity. It is astonishing to see the rapidity with which the scar tissue disappears as the result of adequate drainage. In those cases in which the urachus is enlarged and adherent to the sac, and where this tube can be readily reached, it is advisable to ligate and cut it, as there is a possibility of urine escaping later from the abscess sac.
CASES OF ABSCESS OF THE ABDOMINAL WALL DUE TO INFECTION OF REMAINS OF THE URACHUS, AND NOT COMMUNICATING WITH THE BLADDER.
I have not cited all the recorded cases, but have included only those that are especially convincing.
Suppurating Cyst of the Urachus. — Arrou* reported the case of a patient operated upon by Tricot. A soldier, who gave absolutely no history of bladder trouble, complained of vague pain in the umbilical region. The pain became acute, and during his march he had to bend forward. He had no nausea or intestinal disturbances; urination was normal, the temperature unaltered.
Examination revealed a plaque as large as a hand a little below the umbilicus. This was painful, but there was neither edema nor reddening. Gradually a little swelling was noted. The patient had some pain and fever.
Operation. — An exploratory operation under local anesthesia was determined upon, the condition being thought to be due to an abscess of the abdominal wall. But almost as soon as the patient reached the operating room an escape of a small amount of pus was noted coming from the lower margin of the umbilicus. A probe introduced into the small orifice descended downward and backward into the cavity, which was 6 cm. long in its vertical direction. The patient was at once anesthetized, and a cavity was opened; this proved to be as large as a mandarin orange, and contained a calculus the size of an olive, like a piece of mortar incompletely dried. The cyst lining resembled an inflamed mucosa. Unfortunately, both sac and calculus were lost. The upper end of the sac ended at the bottom of the umbilicus; the lower extremity terminated in the closed cul-de-sac. Attached to the lower end of the sac was a cord the size of the little finger; this cord gradually became smaller and terminated in the fundus of the bladder. There is no doubt that it was the urachus.
The peritoneum was opened above and laterally, the intestine projected. The urachus was cut across with a cautery at a point several millimeters above the bladder. The sac was completely removed and the wound closed. The patient made a good recovery.
Abscess Between Umbilicus and Pubes.f- "Mrs. C. L. R., aged thirty-three, Shenandoah, Ohio. Physician, Dr. J. M. Fry. Married twelve years; one child, aged eleven years; labor normal; no miscarriages; appetite fair, but much vomiting; kidneys normal; menstruation normal. Patient had suffered from her present trouble for about a year, but no diagnosis had been
~~Arrou: Kyste suppure de l'ouraque. ' Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi,~~
832.
t Baldwin, J. F.: Large Cysts of the Urachus. Surg., Gyn., and Obst., June, 1912, xiv, 636.

572 THE UMBILICUS AND ITS DISEASES.
made until about three weeks before I saw her, which was March 29, 1901. In the previous July she had had a feeling of fulness and was as large as though pregnant six months. In September much of this fulness disappeared, but it again increased. When I saw her, the uterus was pushed forward and to the right by a tumor, which did not seem to involve the uterus but which extended from the pubes to the umbilicus. This tumor was cystic, and apparently about the size of an adult head. It could not be said to be movable, but did not seem to be very firmly fixed. Dr. Hunter Robb, of Cleveland, and myself saw the patient together in consultation, and assumed that the tumor was ovarian.
"She came to Columbus and was operated on April 24, 1901, Dr. Fry being present. When under the anesthetic the uterus was found, as before, pushed forward against the bladder, and the cyst could be very distinctly mapped out. On opening the abdomen we found the transversalis fascia to be much thickened. It was dissected through with great care. On getting through there was a gush of pus. With the fingers on the inside the incision was enlarged sufficiently for thorough examination. A large quantity of pus was evacuated, together with a considerable amount of more or less necrotic material, resembling somewhat disintegrated omentum (as in one of the cases mentioned by Doran). The cavity having been entirely cleaned out, the sac was found to be a smooth and rather thick membrane. The peritoneal cavity itself had not been entered. In the pelvis the uterus was found standing up, as it were, distinctly in the cavity, though covered by the membrane, as were also its appendages. The connection of the membrane with the surrounding parts seemed to be so firm as to render any attempt at its enucleation undesirable. The cavity was therefore drained, the incision being only in part closed.
"Patient stood the operation well, made an excellent operative recovery, and returned home in due time. Dr. Fry reported, under date of March 15, 1904, that the fistula which followed the drainage had closed only about four months before. Patient had been warned as to the probability of a hernia. Under date of September 17, 1911, the patient, in response to a letter of inquiry, reported that her health was as good as ever. From her letter it is evident that there is a small hernia at the point of drainage which perhaps should be operated upon, but seems to be making no special trouble. Menstruation perfectly regular." Baldwin said that the patient has had no further pregnancies.
Infection of the Urachus. — In Bryant's* Case 2 the patient was a man about thirty years of age who had a slight epispadias. He had had for many years a tumor the size of a small cocoanut lying between the umbilicus and the symphysis. He came under observation on account of great swelling and tenderness between the pubes and the umbilicus. The condition was thought to be due to an abscess. The urine was normal. After incision, very fetid material came out, bu1 there was no urinary smell. The cavity was packed with terebene, and some days later urine was discharged from the wound.
Abscess F o r m a t i o n in the Patent Urachus. f — A female child, apparently normal at birth, had abdominal pain and diarrhea and vomiting when three weeks old. When five months old she was sick again, and the mother noticed a protrusion of the abdominal wall below the umbilicus. The swelling
~~Bryant, T.: Brit. Med. Jour., 1898, i, 1390.~~
t Van Hook: Amer. Jour. Obst., New York, 1894, xxix, 624.

"URACHAL INFECTIONS. 573
reached the size of an orange. Hot applications resulted in an opening at the umbilicus, with the discharge of a large quantity of pus. Later on cystitis developed and pus continued to be discharged through the umbilicus.
Van Hook examined the child when it was six months old. She urinated repeatedly during the examination. The urine was quite turbid. The umbilicus projected slightly upward and forward and was apparently pushed in this direction by a tumefaction the size of a small apple, which also pushed forward the abdominal wall between the umbilicus and the pubes. The umbilicus had a red, inflamed appearance. A thin pus trickled from the small opening in the lower umbilical fold when pressure was made on the tumor. There was swelling of the right inguinal glands.
Under chloroform a probe was passed down almost to the pubes, but did not enter the bladder. The opening was dilated and a drainage-tube put in. Recovery followed in a week.
An Infected Urachal Cyst.' — Hornig* reviews the literature and reports a case from Trendelenburg's clinic.
The patient was a girl, three years and nine months old. For several weeks she had complained of painful urination. For eight days the mother had noticed swelling of the abdomen. The child had lost weight. The father said that she had often felt sick, and in the spring had remained in bed for two days.
Operation (December 4, 1902).- — The umbilicus bulged out, forming a nodule the size of a cherry. It was bluish red and covered with thin skin. From the umbilicus to the symphysis the abdomen was half-ball-shaped from tension. Palpation met with a tense resistance. The umbilical swelling collapsed while the child was being bathed, and yellowish-red, thick, fluid masses escaped. On catheterization the urine was perfectly clear and transparent; it contained no albumin nor sediment. The umbilical fluid contained staphylococci, and microscopically many flat cells. After the bladder had been emptied the half-ball-shaped swelling between the umbilicus and the symphysis became less prominent, and by rectal examination, with one hand on the abdomen, the surgeon could make out very clearly a cystic tumor.
The fistulous opening was closed to prevent infection. The incision encircled the umbilicus and extended to 2 cm. above the symphysis. The anterior wall of the cyst was exposed. On account of the danger of peritonitis total extirpation of the cyst was not attempted, but the anterior cyst-wall and the umbilicus were removed. A finger in the cyst showed that it extended downward behind the symphysis, and that it ended blindly in the pelvis. A catheter introduced into the bladder could be felt behind and to the left. The cyst-wall was curetted with a sharp curette to remove any epithelial lining. A drain was laid and the opening closed. By January 13, 1903, only a small, granulating strip, 5 mm. wide, remained.
On microscopic examination no epithelial lining of the cyst could be found. The walls were composed of connective tissue, showing marked round-cell infiltration. They also contained smooth muscle-fibers. Although the epithelium was missing, Hornig felt that the smooth muscle was all that was necessary for diagnosis.
A Case of Hardening of the Linea Alba and Umbilicus. — In some healthy persons Leggf says there may be felt in the linea alba,
~~Hornig, Paul: Zur Kasuistik der Urachuscysten. Inaug. Diss., Leipzig, 1905.~~
t Legg, J. W.: Saint Bartholomew's Hospital Reports, 1880, xvi, 251.

574 THE UMBILICUS AND ITS DISEASES.
between the pubes and the umbilicus, a certain thickness or firmness which is not, however, very marked. He cites an interesting case in which the linea alba between the pubes and the umbilicus was one inch thick, a new growth having its seat apparently in the subperitoneal tissue. This growth was white, dense, tough, and much thicker on the left than on the right of the mid-line. The omentum was thickened. The stomach was small, constricted, and adherent to the omentum. No microscopic examination was made. [The possibility of a malignant abdominal growth in this case cannot be excluded. — T. S. C]
A Partially Patent and Infected Urachus. — Lexer* reports a case coming under the observation of Delageniere. The patient was a boy, five and a half years old, who had a fistula dating from early childhood. At the sixth month a small tumor at the umbilicus opened. Delageniere cut around and then entered, behind the umbilicus, a pocket filled with granulation tissue. Its lower portion communicated with the urachus. In dissecting this out he opened the peritoneum and could feel a string of the urachus passing downward to the bladder. It was isolated for 3 cm. and cut across. The lumen was turned in and closed with sutures. The fistula healed as the result of this procedure, which Delageniere spoke of as partial resection of the urachus. The child remained healthy.
An Infected Cyst of the Urachus. — Page's t patient was a man thirty-six years of age, married, and previously in good health. In March, 1899, he had dull pain about the fundus of the bladder. The pain was intermittent, ceased, and reappeared the second year. In July, 1901, he had sudden violent cramps in the abdomen, followed by diarrhea. The diarrhea ceased in two weeks, but the pain continued. Page suspected appendicitis.
On admission the patient walked bent over. He had great pain in the hypogastric region. His temperature was 102.5° F., pulse 100. He was nauseated. Examination disclosed a circumscribed mass, the size of an average orange, which lay between the umbilicus and pubes, and seemed to be in the abdominal wall. The patient had had a chill the night before. Dr. F. L. Taylor suggested a suppurating cyst of the urachus.
Operation. — Incision three inches long over the mass. In cutting through the fascia the tissues were found to be dense and hard. The operator entered a cavity containing four ounces of thick, flaky fluid, yellowish-brown in color. The abscess cavity was large; the walls were smooth and very thick. In lengthening the incision the peritoneum was accidentally opened. It was at once closed.
The recovery was slow. The cavity gradually became obliterated. The sinus had to be curetted several times, but it healed permanently. The man had formerly weighed 115 pounds; he then weighed 145.
Subperitoneal Phlegmon of the Anterior Abdominal Wall Without Appreciable Cause, Opening Below the Umbilicus; Rapid Healing.! — On p. 5 Vaussy gives the history of phlegmonous subperitoneal inflammation of the anterior abdominal wall, and on p. 6 says that Velpeau, Boyer, Nelaton and Vidal, had cited in their publications
~~Lexer, K.: I'eber die Behundlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73.~~
f Pago, Charles C: The Post-Graduate, New York, 1902, xvii, 1094.
{Vaussy: Des phlegmons sous-periton<£aux de la paroi abdominale anterieure. These de Paris, 1875, No. 445, Obs. 2.

URACHAL INFECTIONS. 575
several examples of vast purulent accumulations developing between the peritoneum and the anterior abdominal wall. On p. 25 he gives Observation 2. A boy, aged eleven, had at first complained of malaise, fever, and lack of appetite, and later of extreme pain in the hypogastric region. This was increased on inspiration. For a time the pain became general throughout the entire abdomen. The parents soon noticed a swelling in the abdomen below the umbilicus. When admitted (October 26, 1875) to the hospital, the boy showed a great deal of depression, had fever, no appetite, but gave no history of chills or vomiting.
On inspection a tumor was found extending from the umbilicus to the pubes. It was in the median line, and extended over to the left 5 cm. and to the right as far as the crest of the ilium. The tumor was hard, possibly fluctuating, but this could not be determined on account of the patient's pain. It suggested in contour a markedly distended bladder. The skin was of normal color; there was no redness nor edema. Rectal examination was negative. It was decided that the condition was due to a subperitoneal phlegmon of the anterior abdominal wall. It was impossible to determine the cause of the phlegmon, as the child had never been injured, nor had he had typhoid fever. The hypogastric region remained painful, the tumor became fluctuating, and a small red point the size of a 50-centime piece appeared immediately below the umbilicus in the median line. Poultices were applied. The pain and redness persisted, and there developed a small tumor the size of a cherry. Fluctuation being evident, a small incision was made with a bistoury and an enormous quantity of pus escaped. This had a very fetid odor, but did not in any way suggest stercoraceous material. By the eleventh of November the fistula had closed and the child left the hospital. The cause of the inflammation in this case was not clear.
[The history, which is characteristic of such cases, suggests remains of the urachus which had become inflamed. — T. S. C]
Suppuration of a Urachal Cyst. — In Weiser's Case 2 the patient was a girl, eleven years old, who was admitted to the Mercy Hospital on April 11, 1905. The child had complained for several days of headache and vomiting and had gradually developed slight tenderness and some pain in the abdomen. At first there had been no localized tenderness and very little distention. One week prior to admission general flatness had been noted with fluctuation. The abdomen had become more and more distended. On admission her temperature was 101.2° F.; pulse, 172; respirations, 30. The child was pale and emaciated and had a dry tongue and an anxious expression. She complained bitterly of abdominal pain, and the entire abdomen was tender, especially about the umbilicus, greatly distended and board-like. The flatness extended from the umbilicus to the symphysis, and from a point two inches to the right of the median line almost completely into the loin on the left. Surrounding the umbilicus was a zone of redness l^g inches in diameter, which represented an area through which the abscess was ulcerating toward the surface. A positive diagnosis was not made prior to operation, but tubercular peritonitis and a suppurative urachal cyst were both considered.
Under anesthesia the abdomen was opened in the mid-line between the umbilicus and symphysis. Absence of the peritoneum made a diagnosis quickly possible. The abdominal cavity was divided into two compartments by the sac-wall, which
~~Weiser, W. R.: Annals of Surgery, 1906, xliv, 529.~~

576

THE UMBILICUS AND ITS DISEASES.

had displaced the intestines almost entirely to the right side of the cavity and walled them off. Almost the entire left side below the umbilicus was filled with the cyst, which had ruptured, as shown in Fig. 243. Except at the point of rupture, the cyst contents were entirely extraperitoneal, although occupying so large a part of the abdominal cavity. Free pus to the amount of several pints was confined to the left side, and was not in contact with the intestines. The position occupied by the mass is fairly well shown in Fig. 243. The urachus was patulous down to within three-eighths of an inch of the bladder, and was ligated at this point. So much of the sac as could be dissected out without tearing up the limiting wall was taken
away, and the abscess cavity washed out and drained with a coffer-dam drain of iodoform gauze. An area 2 x 4j/2 inches was bare of peritoneum at the site of the wound, but there was no trouble from this source.
A Small Urachal Cyst Showing Inflammation.* — ■ Case 23. Autopsy No. 260, 1881. — The body was that of a man, sixty-three years old, dead of arteriosclerosis, hypertrophy and dilatation of the heart, emboli of the lungs, general edema, hypertrophy of the prostate, catarrhal cystitis. The bladder was pear-shaped, and its vertex appeared to reach to within 4 cm. of the umbilicus. When it was opened at the upper end, tenacious and slimy pus escaped. An abscess lay above and behind the top of the bladder. The bladder itself was 11.5 cm. long, and the distance from the vertex to the umbilicus was 8.4 cm. The bladder appeared to be independent of the first abscess (a) . Above the surface of the larger abscess (a) was a smaller one (6), the size of a bean. The cavities of both of these were reddish. Above this point the urachus appeared as a cord, accompanied by the umbilical arteries. The mucosa of the bladder was pale, not ulcerated. On the mucosa of the vertex of the bladder was an extravasation the size of a pin-head, and in the middle of this was a punctiform depression through which a bristle could be passed into abscess (a). The cavity of abscess (a) was 1 cm. long, 0.6 cm. broad. From this abscess cavity a bristle could be passed into abscess h l so that the connection between the two was easily followed. From abscess (b) the urachus could be traced 0.5 cm. toward the umbilicus. Microscopic examination of the walls of the abscesses (a) and (6) showed that they were inflammatory urachal cysts. In some places the characteristic several layers of epithelium were in evidence; at other points the inner surface of the cyst was ulcerated and the connective tissue showed small-round-cell infiltration. The entire length of the urachus in this case was 4 cm.
~~Wutz, J. 15.: Tiber (Jrachus and I'raehuscysten. Virchows Arch., 1883. xcii, 387.~~

Fig. 243. — Urachal Cyst. 'After W. R. Weiser, Case 2, Fig. 2.) The urachus was patulous down to within three-eighths of an inch of the bladder. Above that it had dilated into a large cyst. The urachus was ligated and severed and as much as possible of the suppurating cyst-wall was cut away. The abscess cavity was washed out and drained.

URACHAL INFECTIONS. 577

LITERATURE CONSULTED ON ABSCESS IN THE ANTERIOR ABDOMINAL WALL,
BETWEEN THE UMBILICUS AND THE SYMPHYSIS, DUE TO INFECTION OF
URACHAL REMAINS AND OF URACHAL CYSTS.
Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832.
Baldwin, J. F.: Large Cysts of the Urachus. Surg., Gyn., and Obst., June, 1912, xiv, 636.
Bryant, T.: Brit. Med. Jour., 1898, i, 1390.
Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, n. F., Xo. 89 (Chir. No. 2-1), Leipzig, 189-1, 519.
Heinrich: Ueber beschriinkte, sogenannte aussere oder tuberculose Peritonitis bei Kindern, oder iiber Entziindung der subkutanen Sehicht der Bauchwand und iiber die Bildung von Abszessen und Verhartungen daselbst. Jour. f. Kinderkrankheiten, 1849, xii, 6.
Van Hook, W. : Abscess Formation in the Patent Urachus. Amer. Jour. Obst., New York, 1894, xxix, 624.
Hornig, P.: Zur Kasuistik der Urachuscysten. Inaug. Diss., Leipzig, 1905.
Legg, J. AY. : Cases of Hardening of the Linea Alba and Umbilicus. Saint Bartholomew's Hospital Reports, 1880, xvi, 251.
Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 189S, lvii, 73.
Nicaise: Ombib'c. Dictionnaire encycloped. des sciences medicales, Paris, 1881, 2. ser., xv, 140.
Page, C. C. : Cyst of the Urachus. The Post-Graduate, New York, 1902, xvii, 1094.
Vaussy, F. : Des phlegmons sous-peritoneaux de la paroi abdominale anterieure. These de Paris, 1875, No. 445.
Weiser, W. R.: Cysts of the Urachus. Annals of Surg., 1906, xliv, 529.
Wutz, J. B.: Ueber Urachus and Urachuscysten. Virchows Arch., 1883, xcii, 387.

~~Chapter XXXIV. Urachal Cavities between the Symphysis and Umbilicus Communicating with the Bladder or Umbilicus or with Both~~
General consideration.
Symptoms.
Differential diagnosis.
Treatment.
Instance of a urachal cavity between the symplrysis and umbilicus and communicating with the bladder or umbilicus or both.
Figs. 244 and 245 graphically illustrate urachal cavities communicating with the bladder. Fig. 246 shows in a schematic manner the way in which a distended urachus may open at the umbilicus. Dilatation of the urachus with the escape of urine from both the bladder and umbilicus is indicated in Fig. 247, while in Fig. 248 we see the tremendous quantities of stagnant urine that niay be forced little by little into the pervious urachus when the bladder contracts during micturition. Finally, the valve-like opening is overcome and there is a sudden gush of ammonia cal urine from the urethra; or an opening may develop at the umbilicus; or the urine may escape from both the urethra and the umbilicus.
Sex. — Of the cases here recorded, and in which data as to the sex are available, 14 were in males and 12 in females.
Age. — The youngest patient (Savory's) was thirteen months old. Weiser's patient, a woman of seventy-five, was the oldest. The age table is as follows:
Under ten years of age 4 cases
Between ten and twenty years of age 2 "
Between twenty and thirty years of age 7 "
Between thirty and forty years of age 1 case
Between forty and fifty years of age 4 cases
Between fifty and sixty years of age 1 case
Between sixty and seventy years of age 1 "
Over seventy years of age 2 cases
These figures are of only relative value. Bramann's patient, who came under observation at twelve, had definite symptoms when nine years old. Freer's patient came under treatment at fifty-four, but from the history it was evident that symptoms were first noted when the patient was seven years old. Newman's patient was thirty-nine years old, but he had had an enlargement in the lower abdomen as long as he could remember. Vaughan's patient, a man of forty, had experienced pain in the suprapubic region when seventeen.
SYMPTOMS. The chief symptoms are those referable to the bladder and to the development of a tumor between the symphysis and umbilicus. When infection occurs, constitutional disturbances are superadded.
578

URACHAL CAVITIES AND INFECTIONS.

579

A reference to the accompanying histories will show that the vesical s y m p t o m s varied greatly. Some patients complained of frequent micturition, others of incontinence, while others had difficult micturition, retention, or an almost total inability to void.
In some the vesical symptoms had been of short duration; others had had defi

Fig. 244. — A Dilated Urachus Communicating with the Bladder. (Schematic.) Where such a condition exists, when the bladder contracts during micturition part of the urine escapes from the urethra and part may be forced into the urachal sac. Finally the urachal sac will empty itself into the bladder.

Fig. 245. — Large Accumulation op Urine in a Partially Patent Urachus. (Schematic.) Some patients give a history of cystitis, and a few months later a hard, globular tumor is noted between the umbilicus and symphysis. After the bladder has been emptied with a catheter the tumor still persists. Finally, after a very large amount of fluid has accumulated, it may all be discharged at once through the bladder, or the urachus may open at the umbilicus, allowing the accumulated urine and pus to escape by this avenue. In these cases there is usually a periodic filling and emptying of the urachal sac.

nite bladder disturbances for years. In Patel's case, for example, a child three years old had had incontinence of urine day and night since birth, the urine being passed involuntarily and at frequent intervals. In Freer's patient, a woman fiftyfour years old, vesical symptoms were first noted when she was seven years old. Schnellenbach's patient, who was sixty-six years old, had had frequent micturition for one year and pressure was necessary to start the flow. When the patient was

5S0

THE UMBILICUS AND ITS DISEASES.

catheterized, 1500 c.c. of urine came away. Worster's patient gave a history of having developed a cystitis with incontinence after diphtheria, and eleven years before coming under observation had passed a large amount of pus from the urethra.
In some cases the urine was turbid and contained pus and occasionally blood. In other cases the urine was clear; occasionally, as in Graf's, Lexer's, and Matthias'

Fig. 24(i. — Ax Infected Urachus Opening at the Umbilicus. (Schematic.) 1 (ccasionally urachal remains become infected, and after a time open at the umbilicus. In i hose cases in which the vesical end of the urachus i- closed i here is no escape of urine from the umbilicus, the discharge being purulent or slimy in character.

Fig. 217. — A Patent Urachus Dilated in its Middle Portion. (Schematic.) In such cases the middle portion of the urachus may become markedly distended, sometimes containing a liter or more of decomposing urine. (See Fig. 248.)

cases, the patients had previously had a gonorrheal infection. This naturally confused the clinical picture to some extent.
P a i if. — More or less pain in the lower abdomen was a frequent symptom. In Bourgeois' ease there was an almost insupportable feeling of tension in the lower abdomen, and the suprapubic region was particularly sensitive after fatigue. In Matthias' case there was a feeling of pressure in the lower abdomen, accompanied by malaise. Worster's patient had to bend forward at an angle of 45 degrees to

URACHAL CAVITIES AND INFECTIONS.

581

get relief, and was incapable of stooping down to pick up anything. Newman's patient suffered much pain, walked with difficulty, and had an anxious expression. Hind's patient had a steady pain in the lower abdomen. Suddenly something gave way, there was a feeling of relief, and a large amount of pus escaped from the bladder.
The Umbilicus. — With the progress of the disease the umbilicus in about half of the cases became inflamed and ruptured, with the escape of pus, and later of urine. In Bourgeois' case a small, soft, red tumor the size of an almond developed at the navel. During micturition it would become prominent and painful. It was opened and urine escaped.
Bramann's patient, two years after vesical symptoms had been noted, had a sudden discharge of urine from the umbilicus. In Hastings' case the urine for a time ceased entirely to pass from the urethra. On one occasion, when the patient had not voided at all for a long period, there was a sudden gush of two quarts from the umbilicus.
Lexer's patient, one and a half years after the onset of symptoms, complained of pain in the umbilical region. The tissues swelled up, became red, and a quantity of purulent material escaped. On pressure pus and urine were discharged from the umbilicus. Savory's patient developed a tense umbilical
swelling two to three inches in diameter. This was tender during micturition. It was opened later, pus escaped, and finally nearly all the urine was passed by this avenue.
In Schnellenbach's case there was pain in the umbilical region, followed by the escape of pus. Vaughan's patient had poultices applied to the umbilical region. Two weeks later pus and urine passed from the umbilicus. Occasionally the opening would close for a couple of days. This closure was accompanied by much pain,

Fig. 248.

Urine in

Accumulation op a Large Quantity Urachal Pouch. (Schematic.) Occasionally the urachal pouch is very large, and when the bladder contracts, part of the urine escapes from the urethra, part is forced up into the sac. An opening may or may not exist at the umbilicus. If there be no exit at the umbilicus, the valve-like opening between the urachus and bladder is after a time temporarily overcome, and suddenly there escapes from the bladder a large quantity of ammoniacal urine mixed with pus, the urachal tumor at once disappearing. Such a sac will fill up and empty periodically.

582 THE UMBILICUS AND ITS DISEASES.
which was not relieved until the fistula reopened. The discharge was so offensive that the patient could not mingle with his friends. Worster's patient also developed a tumefaction in the umbilical region, followed by the escape of pus and urine.
The opening in Weiser's Case 3, did not develop at the umbilicus, but 2 inches below it. Urine only escaped; at no time was there any pus.
When the infection of the urachus extends up to the umbilicus, it is but natural that the latter should be secondarily involved, particularly when much tension exists in the sac.
Constitutional symptoms have not been at all prominent in these cases, evidently because there was a certain amount of drainage by the bladder, umbilicus, or both. In Hastings', Lexer's, and Morgan's cases fever was present, and in Morgan's case there was vomiting accompanied by diarrhea.
The carefully recorded case reported by Hastings in 1829- (p. 589) is well worth a thorough study. This case clearly shows that, notwithstanding most alarming symptoms, such as convulsions, the patient may recover. Savory's patient, a sickly child thirteen months old, died; in this case the inflammatory process had extended to the abdomen, as indicated by the adherent omentum. Ball's eightyear-old child died of peritonitis.
In Xicaise's (p. 597) and Roser's (p. 598) cases the patients successfully passed through a pregnancy while suffering from an infected urachal cyst. Roser's patient miscarried during a subsequent pregnancy four years later.
The urachal cyst varies considerably in size. It is attached to the bladder below and to the umbilicus above, and any great increase in size, as a rule, will be in its central portion. In Bramann's case the tumor resembled a long sausage. In Worster's patient it was recognized as a large cord, two inches in diameter. In Freer 's case, when the patient was fourteen years old, it was the size of an apple, but when she came under observation, at fifty-four, it was much larger. In Patel's case the tumor was the size of two fists. Vaughan's patient had a pyriform tumor three inches long, and having a capacity of about three ounces. Schnellenbach's tumor was the size of a head, while in Timmerman's case the sac contained about 1500 c.c. of fluid.
Urachal cysts communicating with the bladder can hardly reach as large proportions as some of those that have no external opening. In Roser's case, however, notwithstanding the opening into the bladder, the sac contained between three and four liters of fluid.
The walls of the sac may be thin or thick, depending in a large measure upon the amount of inflammatory reaction. In Newman's case the walls were thin; in Bramann's case they were several millimeters thick, and in Matthias' case they varied from 2 to 20 mm. in thickness.
The interior usually consists of but one cavity. The inner surface may be perfectly smooth, or lined with granulation tissue. On histologic examination the inner surface may have a lining of transitional epithelium, as noted in Bramann's case, or of one layer of squamous epithelium, as found by Schnellenbach. In the latter 's case the underlying stroma showed small-round-cell infiltration.
The cyst fluid in Patel's case was pale yellow. In the greater number of the cases it consisted of urine and pus. The urine in Newman's and in Roser's case was very ammoniacal. In Vaughan's case the cavity contained laminated clots.

URACHAL CAVITIES AND INFECTIONS. 583
DIFFERENTIAL DIAGNOSIS.
The history of cystitis, coupled with the development of a tumor just above the symphysis, is strong presumptive evidence of a dilated urachus, particularly if the tumor increases in size when the patient has not voided for several hours, or if it decreases markedly in size after catheterization, accompanied simultaneously by pressure on the tumor. There are some cases, however, in which the effort to void forces a large part of the urine out of the bladder into the sac, only a portion escaping from the urethra. In such cases the tumor is larger after the bladder has been emptied.
With the aid of the cystoscope the diagnosis becomes more easy. In Matthias' case, for example, on exploration of the bladder a transverse oval opening was found near the top of the anterior blaclder-wall. This passed into a funnel-shaped diverticulum, which extended upward toward the umbilicus.
Occasionally a suppurating dermoid or an inflamed appendix ulcerates through into the bladder. When the dermoid opens into the bladder, the tumor is situated in one side of the pelvis. The urachal tumor, on the other hand, is in the mid-line, and lies in the anterior abdominal wall. Furthermore, in the case of a dermoid cyst, on cystoscopic examination it may be possible to see a tuft of hair projecting from it into the bladder. When an appendix opens into the bladder, there has usually been a definite history of appendicitis and the discharge passing from the bladder has a distinctly fecal odor. The following case although not exactly germane to the subject has several points in common, and is of such interest that I shall briefly report it.
In May, 1907, I saw a very interesting case of extra-uterine pregnancy, in which, long after the death of the fetus, the sac opened into the bladder. The patient, L. S., colored, aged thirty-three (Gyn. No. 13806), was admitted to the Johns Hopkins Hospital on May 3, 1907. For the previous five years she had complained of much pain in the lower right abdomen. This was usually dull, and occasionally accompanied by nausea. Three years before admission she was supposed to be pregnant and to have proceeded to about the eighth month. Severe, labor-like pains lasting five minutes suddenly developed, and the patient passed blood from the uterus. Shortly afterward she noticed that the abdominal girth was diminishing, and that a hard, tender lump was present in the right lower abdomen. This gradually became smaller. She gave no history of chills or of fever, but had had some vomiting, had suffered from pain from time to time, and had lost in strength and in weight.
On admission the right lower abdomen was distended by an irregular nodular mass, which on palpation gave a peculiar feeling of crepitus. On pelvic examination the uterus was found slightly enlarged and lying posteriorly. On the right side was a pelvic mass attached to the side of the uterus.
On catheterization under ether a large amount of thick, tenacious urine came away, and the catheter came in contact with a substance feeling very much like a stone.
Operation. — A median incision, after liberation of the adherent omentum, disclosed a large, irregular mass in the right lower abdomen. The large and small bowel were found densely adherent to the sac. The small bowel was dissected free, but its coats were slightly injured.
The sac contained a large number of fetal bones (Fig. 249) . The bladder was

584

THE UMBILICUS AND ITS DISEASES.

densely adherent to the mass, and after it had been freed, an opening was found to exist between the sac and the bladder. One of the long bones, a femur, was seen projecting from the sac into the bladder, and the portion lying in the bladder was heavily coated with urinary salts (Fig. 250) . The vesical opening was closed.
In the cecum, near the ileocecal valve, long bones projected from the fetal sac into the lumen of the bowel.. There was a second opening into the large bowel six inches above the ileocecal valve. After closing the intestinal openings and removing the appendix, which was thickened and indurated, I also removed a parovarian cyst from the right side. The abdomen was then drained. The patient made a good recovery.
In such a case as this the previous history pointed to a pregnancy. Bimanual examination revealed an intraabdominal tumor situated on one side, and not in the mid-line. Cystoscopic examination would have determined the presence of a foreign substance projecting into the bladder.
From the foregoing it is seen that urachal tumors connected with the bladder are relatively easy to diagnose.

Fig. 249. — Fetal Bones Removed from an Old Extra-uterine Pregnancy Sac.
Oyii. No. 13806. The bones have been roughly assembled. They are very well preserved. 'J'Ik- ends of t wo long bones projected into the lumen of the cecum :i in 1 one into I In- cavity of the bladder. The end of this bone is heavily coated with phosphates. This is particularly well shown in Fig. 250.

TREATMENT. WJiere a marked infection is present, it is advisable merely to open up and drain the sac. If possible, at the same time the bladder should be separated from the sac and the vesical opening closed. The sac is then packed and allowed to contract down.

URACHAL CAVITIES AND INFECTIONS.

585

If there is little danger of infection, the umbilicus is encircled and removed, together with the sac, and the bladder opening closed.
The vesical symptoms usually disappear as soon as the source of irritation — the dilated urachus — is eliminated.

EXISTENCE OF A URACHAL CAVITY BETWEEN THE SYMPHYSIS AND UMBILICUS, AND COMMUNICATING WITH THE BLADDER OR UMBILICUS OR BOTH.
Quite a number of the cases in the literature were not sufficiently definite to warrant citation; only those that clearly illustrate the condition have been selected.
Cystitis with Tu m o r Formation in the Bladder.— In 1882 Ball* saw a boy eight years old who had suffered from incontinence of urine at night from birth, and during the previous six weeks also by day. In March, 1882, the urine was bloody and contained pus, but the boy improved, although he was still complaining of pain in the lower abdomen. When he next came to Ball, in January, 1883, he had an umbilical fistula, which he stated had appeared three weeks previously after rupture of an abscess. Since that time all the urine had passed through the navel. The urethra was very small, but later a moderate amount escaped by this passage also.
The treatment consisted in cauterizing the opening. This was clone three times. The parts remained healed only for a short time. A fourth operation was of a plastic nature; the fistula remained closed for two months. One month later the boy died of peritonitis.
At autopsy the urinary organs were removed entire. On the next day the cavities were first injected with colored
lard through an opening in one of the ureters. A minute hole about 13^ inches below the umbilicus and 2}^ inches above the fundus of the bladder was found. From this urine had escaped into the abdominal cavity. In the upper abdomen there was abundant evidence of a recent peritonitis. The omentum was adherent to the anterior abdominal wall, apparently as the result of a long antecedent inflammation. The amount of fluid in the abdominal cavity was small, but there was an abundance of lymph matting the abdominal viscera together.
~~Ball, C. B. : Case of Pervious Urachus with Remarkable Disease of Bladder. Trans. Acad.~~
Med. Ireland, 1883-84, Dublin, 1884, ii, 376. This case is probably identical with that referred to by Freer in 1887. Although the age does not correspond, the findings were precisely the same.

Fig. 250. — A Phosphatic Deposit ox the End of a Long Bone. Gyn. No. 13S06. One end of this bone projected into the bladder and has a heavy covering of urinary phosphates. This is clearly evident in the lower part of the picture.

586 THE UMBILICUS AND ITS DISEASES.
The ureters and pelves of the kidneys were much dilated. The bladder was very small and firm; the walls were much thickened. From the fundus of the bladder to the umbilicus extended a tongue-like cavity, 23^ by 1% inches. This was situated between the peritoneal covering and the muscular layers of the anterior abdominal wall. It was in the anterior wall of this cavity that the fatal rupture had taken place.
During the separation of the bladder from the other pelvic contents it was found that the viscus was surrounded by cicatricial adhesions. The bladder-walls were enormously hypertrophied, and projecting into the cavity were a number of newgrowths which resembled the columnse carnese of the heart. Some were attached by one end only to the vesical wall, the other end being free in the cavity; others were attached at both ends, but were free along the sides, so that a probe could be passed between them and the bladder-wall. Microscopic examination showed that they were composed of fibrous tissue with a covering of mucosa.
The bladder was divided into two compartments by a septum. This was attached posteriorly about the middle of the trigonum. Immediately above the septum was a minute opening leading off into the cicatricial tissue in front of the bladder. There had evidently been an extravasation of urine which had become localized as the result of an inflammation.
The fundus of the bladder communicated with the cavity lying between it and the umbilicus by a wide opening. The cavity contrasted remarkably with the bladder proper. Its walls were extremely thin and the inner surface smooth. The openings by which the extravasation had taken place into the peritoneal cavity were two in number — one a small aperture, the other a rent apparently of recent origin.
\Yhether this case was one in which the urachus had remained patent up to the umbilicus and in which, upon supervention of bladder obstruction, suppuration had occurred at the umbilical cicatrix, leaving a fistulous opening, or whether, in consequence of an extravasation of urine in the neighborhood of the fundus, an abscess cavity had been formed which followed the track of the obliterated urachus, are among the interesting pathologic features of the case.
An Abscess Between the Umbilicus and Symphysis Opening at the Umbilicus. — On August 7, 1821, Bourgeois* presented to the Paris Society a young soldier, aged twenty, who had at the lower portion of the umbilical cicatrix a granular excrescence the size of a small lentil. At its summit was a minute cavity, from which there escaped, drop by drop, and sometimes in a jet, a fluid which resembled urine. The patient had pain in the anterior abdominal wall which extended from the pubes to the umbilicus. Several times after fatigue the discomfort became severe and it was necessary to apply liniments. Later he had an attack of retention of urine and complained of a feeling of insupportable tension. After several days a round tumor developed. It was the size of an almond, and was red, soft, and fluctuating. When the patient attempted to urinate, this mass became tense. He was brought to the hospital and came under the care of Larrey, who incised the tumor. The skin was very thin, and there escaped a large quantity of serosanguineous and purulent fluid of a strongly urinary odor, which suggested a communication between this cavity and the urinary tract.
~~Bourgeois: Jour. gen. de med., annee 1821, lxxvi, 219.~~

URACHAL CAVITIES AND INFECTIONS. 587
Tumor Formation Between the Umbilicus and Symphysis Due to Remains of the Urachus. — Bramann,* in 1887, reported a case from von Bergmann's clinic. The patient was a girl of twelve who had been normal until her ninth year. She then complained of pain and frequent micturition, and there was a discharge of pus and a little blood from the bladder. Two years later the urine suddenly came through the umbilicus and continued to pass by this route, although her physician tried to close the opening by cauterization. The urachus was dissected out and the bladder opening closed. A fistula followed, and this still persisted up to the time that the case was reported. When she came under observation a granulation the size of a pea was detected at the umbilicus; in the center of this was a depression from which urine escaped. Behind the abdominal wall, in the median line, and below the umbilicus, and reaching to the symphysis, was a long, sausage-shaped tumor, which was soft and adherent to the umbilicus, but movable low down. Rectal examination showed that the lower end passed to the bladder. The urethra was normal.
After appropriate treatment for the cystitis a radical operation was undertaken. The fistulous tract was dissected out as far as the bladder, but the peritoneum tore at one point and the omentum protruded. It was wiped off and replaced and the peritoneum closed. The urachus was several millimeters thick, dark red, yielding, and lined with a membrane resembling mucosa. Here and there it was apparently lined with granulation tissue. It opened directly into the bladder. Microscopicexamination showed that the canal was lined with transitional epithelium, next to which was connective tissue, and external to this non-striped muscle-fiber. After operation the fistula persisted.
Escape of Urine From the Umbilicus, f — The patient was a married woman, forty years of age, suffering from what was said to be a vesicoumbilical fistula. This patient came under Freer's care while he was resident surgeon at the Ward's Island Hospital. She complained of a chronic purulent discharge from the umbilicus, as a result of which she had become so exhausted that she was scarcely able to walk. Freer discovered at the umbilicus a fistulous opening. A uterine sound was introduced and glided without obstruction downward almost its entire length, and by giving it a lateral motion, Freer found that it entered a cavity which had a breadth of almost three inches in its widest portion. On removal of the probe pus welled up from the opening, and when pressure was exercised from below upward, several ounces of pus escaped. The cavity was washed out with a 2 per cent carbolic-acid solution, and it was not until the disproportion between the amount of fluid injected and that which returned was noticed that the true nature of the case was surmised. This was afterward proved by the injection of a starchy solution, after which the bladder was emptied and the iodin test applied to the evacuated fluid, which yielded the characteristic appearance of the blue iodid of starch. The patient was put on a nourishing diet, and after local treatment in a short time the purulent discharge ceased and the fistula closed spontaneously. She stated that a similar result had been achieved at other hospitals on previous occasions, but that the fistula, after remaining closed for a short time, would then reopen, with a repetition of the above symptoms. Sometimes,
~~Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir.,~~
1887, xxxvi, 996.
t Freer, J. A. : Abnormalities of the Urachus. Annals of Surg., 1887, v, 107.

588 THE UMBILICUS AND ITS DISEASES.
when she strained, urine would be forced up through the opening, but this was so infrequent that she considered it of slight importance. She had no difficulty in passing the urine by the natural channel.
Cyst of the Urachus Communicating With the Bladder. — Freer* cites a case reported by Helmuth in The Homeopathic Journal of Obstetrics, 1884, vi, 24. This patient was a married woman, fifty-four years of age, of small stature and slight build. At the age of seven years her abdomen appeared to be enlarged; at fourteen a tumDr the size of an apple appeared at the umbilicus and burst, sending forth a stream of fluid with considerable force. Her menses ceased at the age of forty-four, after which her abdomen became enlarged and sensitive to pressure. Incontinence of urine was a source of great discomfort to her, especially at night, when the dripping would awaken her. Helmuth withdrew with the aspirator about a quart of viscid, dark fluid, which showed "inflammatory" and pus corpuscles. Subsequently, when performing an ovariotomy, after dividing the peritoneum, he says: "I came upon a substance which puzzled me. It looked something like a cyst- wall, but was so densely adherent to the abdomen at the umbilicus that it was impossible to separate the adhesions. Laterally, on each side of the incision, the substance disappeared. After vainly endeavoring to push this sufficiently aside, I determined to incise it, which I did. A gush of fluid followed, and for a moment I believed I had opened the sac. Upon introducing my finger into the incision I soon discovered that the canal communicated directly with the bladder. I then forcibly drew this emptied sac aside, and without difficulty removed the [ovarian] tumor. From some experience in suprapubic lithotomy I determined to bring the wall of the bladder-cyst together with carbolized catgut, which I did. A self-retaining catheter was placed in the bladder and the woman put to bed. The patient died on the evening of the fifth daj' from peritonitis." Helmuth says the patulous and cystic urachus, leading from the fundus of the bladder to the umbilicus, accounts for many peculiar symptoms detailed by the patient.
That the bursting of the umbilicus in early life, when the "water spouted up to the ceiling," was due to the rupture of the external wall of the cyst was proved by the cicatrix, smooth and white, which occupied the site of the umbilicus.
Persistence of the Urachus in Adult Women. — Garriguest did an autopsy on a woman aged forty-five. He found that, owing to the presence of a dilated urachus, the bladder extended as far as the navel, where it was closed. The patient had been operated on for myoma ten days before and had died of nephritis. The urachus was noted at the time of operation. The bladder extended to the umbilicus and lay between the aponeurosis of the abdominal muscles and the transversalis fascia on one side, and the peritoneum on the other.
An Infected Urachus Communicating With the Bladder and U m b i 1 i c u s . — Graft cites the case of a man aged twenty. At twelve years of age he had inflammation of the diaphragm, and four years later gastric fever. A year and a half before Graf saw him he had noticed that the urine escaped from the umbilicus. The tissue in the vicinity of the umbilicus was somewhat swollen, reddened, and painful. He did not know whether he had had fever. On admission he was found to be pale and anemic. He had a frequent desire to
~~Freer, J. A.: Op. cit. t Garrigues, H. J.: Med. Record, New York, 1899, lvi, 720.~~
% Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896, 16.

URACHAL CAVITIES AND INFECTIONS. 589
urinate. He had pain in the abdomen, and from time to time fluid escaped from the umbilicus. Passing downward in the mid-line from the umbilicus was a hard cord, as wide as two fingers, which could be felt going toward the bladder. The symptoms indicated a vesical catarrh, and there was a gonorrheal inflammation of the urethra. After lavage of the bladder, carried out for three weeks, the patient was better. The pus had stopped escaping from the umbilicus.
Operation. — The umbilicus was cut around and the cord dissected out. The peritoneum was opened over an area of 10 cm. It was walled off with iodoform gauze; the bladder opening, which was about 0.5 cm. in diameter, was closed. The patient made a good recovery.
The inner surface of the fistula consisted of granular tissue. In places it had grown into the lumen. Only near the umbilical opening had the cavity an epithelial lining, the cells being of the squamous type.
A Singular Case of Ischuria.* — "On the 9th of April, 1814, M. H., aged twenty-three, was admitted an in-patient of the Worcester Infirmary. She represented herself as having been particularly healthy. Within the last week she had been exposed to cold, whilst the catamenia were flowing abundantly. For the first day or two she appeared to suffer only from feverish symptoms; soon afterward, however, the secretion of urine became very deficient, and she had difficulty in passing it.
"On the evening of her admission she became much worse, and complained specially of pain and tenderness over the whole of the lower part of the abdomen and in the loins. There was vomiting and a disposition to convulsions. The lower part of the abdomen was much distended. A catheter was introduced, and ten ounces of urine were drawn off, after which the pain was relieved. She was ordered to take a scruple of cathartic extract immediately, and one drachm of sulphate of magnesia, dissolved in camphor mixture, three times a day.
"The next morning the bowels had not been moved. She was afflicted with severe headache, as well as the abdominal pains. She had passed no water, and was delirious during the night.
"She was cupped on the back, and had a blister applied, and took cathartic mixture every four hours till the bowels moved freely; after which she w T ent into a warm bath.
"The symptoms remained for several days very much in the same state. Delirium usually came on during the night. No urine was passed by the natural effort, but about three ounces were drawn off by the catheter in the course of twenty-four hours. She very frequently vomited, and suffered much from pain, tenderness, and tension of the lower part of the abdomen.
"On the evening of the 17th insensibility came on, for which a blister was applied to. the back of the neck; the pulse was sixty. An active aperient was given.
"On the 19th no improvement had taken place, for the vomiting was incessant, and the pain in the abdomen and back was more severe. Pulse, 80. She was bled three days in succession, with some alleviation of the pain, but the abdomen became generally enlarged and very tender; there also ceased to be any urine drawn from the bladder by the catheter. This continued to be the case for five days. The bowels were open. She took saline diuretics without avail.
~~Hastings, Charles: London Med. and Phys. Jour., 1829, X. S., vi, 515.~~

590 THE UMBILICUS AND ITS DISEASES.
"On the 25th there was much vomiting, pain, and distention of the abdomen, but she passed a little urine. Pulse, 80. She was bled to eight ounces.
"On the 27th a bloody discharge appeared at the umbilicus, after which the abdominal pain and tension were relieved. She also passed some urine by the urethra. The vomiting was, however, worse than it had previously been.
"The bloody discharge from the umbilicus and the other symptoms continued very much the same till the 2d of May, when there was a discharge, of urinous appearance and smell, from the umbilicus. She had passed no urine by the urethra for three days. The head was very painful, the pupils dilated; pulse, 56; bowels costive. Some leeches were applied to the temples, and a blister to the back of the neck; a brisk purge was administered. The catheter was introduced, but no urine found in the bladder.
"The discharge of urine from the umbilicus continued till the 5th, when the catamenia appeared, but quickly vanished. The abdomen became less tense and tender; there was not so much vomiting ; the bowels were open.
" From the 7th to the 9th there was no discharge of urine from the umbilicus, nor was there any passed by the urethra; as a consequence, the abdomen became much distended and severe pain followed, with vomiting. The tension was most remarkable at the umbilicus, forming a circumscribed tumor.
"On the 10th, in the morning, six ounces of urine were drawn off by the catheter; and in an hour after, two quarts of urine of the same appearance gushed from the umbilicus. This was followed by much relief of the abdominal pains. The discharge of urine from the umbilicus continued for three days and was accompanied with great improvement of the general symptoms.
"The amendment, however, did not last, for the discharge from the umbilicus again ceased, and for three days the vomiting, the headache, the abdominal tension and pain returned with their former severity.
"On the 17th the catheter was introduced into the bladder and no urine was found. In an hour after this, two quarts of urine passed from the umbilicus, and soon afterward great relief was experienced.
"From this time to the 25th there was little variation; but the young woman suffered during that interval very much from vomiting and daily passed urine from the umbilicus. The catheter was passed every day, and no urine was found, but the bladder contracted strongly on the instrument; sometimes, immediately after the catheter was removed, a discharge of urine would take place by the umbilicus, and once as much as three quarts were thus passed.
"On the 26th, for the first time after many days, four ounces of urine were drawn from the bladder. Each succeeding day this quantity was now increased and the quantity passed by the umbilicus was diminished. There was also a general improvement of the symptoms, with the exception of vomiting; this continued obstinate. All this time the medicine that she took was confined chiefly to the class of purgatives; blisters were also applied to the neck and epigastrium.
"The bladder was regularly emptied every day by the catheter for more than a month after this date, during which time the abdominal pain and vomiting subsided, and there was no discharge from the umbilicus. Early in July she began to pass some urine, and the power over the bladder was gradually restored. She was

URACHAL CAVITIES AND INFECTIONS. 591
discharged in the middle of July in tolerable health, but still often complained of pain in the pelvic region. She menstruated.
"Observations. — This curious case of ischuria is well worthy of consideration. The remarkable sympathy observable between the brain, the stomach, the kidneys, is common to all cases of this description, and is so obvious as not to require any further comment.
"The very remarkable feature in the case is the occurrence of the urinary discharge from the umbilicus many days after the ischuria had been noticed. Such instances, although rare, are not without parallel in the annals of medicine. Schenck relates two instances of this kind. In the one, a male, the urine was discharged in consequence of an obstruction at the neck of the bladder, 'tanquam mictione ex umbilico,' for many months without any detriment to health. In the other, a female, and more resembling the one now related, 'cum suppressa per multas dies fuisset urina, tandem per umbilicum urinam profuclit.' (Schenck, Obs., Lib. iii, deUrina, p. 489.)
"The interesting question is to determine in what manner the urine is conveyed to the umbilicus in these instances. The urachus offers itself as a means by which the discharge may be determined to that part, and it seems probable that, in the case of mechanical obstruction related by Schenck at the neck of the bladder, a channel of communication was formed by the urachus between the bladder and the umbilicus. But, in the case we now remark upon, there had been no urine secreted into the bladder long before its appearance at the umbilicus, nor was there for some time after; and the first discharge from the umbilicus was not of a urinary but bloody nature. We must consequently, I think, regard the urinary discharge in this instance as vicarious, and as proceeding probably from the peritoneal surface. This view seems confirmed by the great abdominal distention, which took place for some time previous to the discharge from the umbilicus, when it was invariably found, from introducing the catheter, that the bladder was empty, and that it contracted on the instrument.
"Some cases of this description have been placed upon record by eminent men worthy of great credit. There is none, perhaps, more deserving of attention than that by Platerus, which is thus related by the renowned Sennertus: 'Puellae cuidam annos natae tredecim, cum aliquando copiose minxisset, urinam subito suppressam esse, atque tunc aquam serosam ex aure dextra adeo affatim coepisset effluere, ut una vice mensurae duae ssepe emanarint, idque dies aliquot.' He then adds that, on diuretics being administered, the urine was passed freely from the bladder, and the discharge from the ear ceased; but as soon as the diuretics were discontinued, the discharge again took place from the ear, but was altogether removed by general terebinthinate remedies, and local repellents to the ear. The health did not suffer. (Sennerti Opera, Lib. iii, p. 8, § ii, cap. ix.)
"In our case it was evident that much inflammatory action was going on in the pelvic viscera previous to and during the discharge of urine from the umbilicus; and there was a considerable sympathy of the general health with the local inflammatory action.
"I may further add, as a notice to this case, that the young woman was again admitted into the infirmary in May, 1827, for paralysis of the lower extremities, from which she recovered by appropriate remedies. The urine for a time was drawn off by the catheter, but there was no return of the former disease."

592 THE UMBILICUS AND ITS DISEASES.
Umbilical Urinary Fistula in a Middle-aged Man.* — ( lase IV. — The patient was a middle-aged man, who complained of a tender and irritable bladder when he was jolted. A fixed pain developed just above the pubes, and he noticed an increased desire to urinate. A hardness could be detected above the pubes. Suddenly the patient felt something give way, and pus passed from the bladder through the urethra. He was greatly relieved. Recovery followed, and three years later he was well. Hind thought that in this case there had been an abscess of the patent portion of a urachus.
Cyst of the Urachus. — In discussing Douglas's paper Illf said that recently he had removed a cyst of the urachus as large as two fists without difficulty. The patient was a woman who had some prolapse of the anterior vaginal wall, and when she attempted to pass her urine, some of it passed into the cyst and some escaped through the urethra. This did not have the effect, however, of producing an inflammatory condition about the cyst. The condition was annoying to her, because she had to pass her urine in installments, as it were.
The operation consisted in removal of the cyst and ligation of that portion of the duct which entered the bladder. As he was closing the wound he said to himself: This is a dangerous procedure, and it is likely that this ligature will not destroy the epithelium and that the bladder will open in a short time." Some infiltration of urine taking place, he removed the ligature, cut the duct very short, turned in the edges, and closed it over, as a surgeon would do with an appendix stump.
Cystitis Followed by the Opening Up of a Partially Patent Urachus, Producing a Urinary Fistula at the Umbilicus. — Lexer! reports the case of a poorly developed young man, twenty years old, who said that previously he had never noticed anything abnormal at the umbilicus. A year and a half before admission, after several weeks of difficulty in urinating, the urine being cloudy, he had pain in the region of the umbilicus, the tissue in the vicinity of the navel swelled up and became red. Shortly after a quantity of purulent fluid escaped from the umbilicus. The bladder discomfort became more severe; he frequently had fever and chills and became thinner. In addition to a marked degree of cystitis there was blennorrhea of the urethra. Gonococci were isolated from the urethral discharge. On account of the swelling and inflammatory infiltration, the fistula at the umbilicus was not visible, but the umbilical funnel filled up when pressure was made by the patient, and when pressure on the bladder was exerted the umbilical cavity filled up with pus and foulsmelling urine.
The cystitis was first treated. In the washing-out of the bladder purulent flocculi escaped from the umbilicus, so that finally the entire fluid escaped from the umbilical opening. Nevertheless, it was impossible to introduce a sound farther than 2 cm. into the fistula. By the third Aveek the patient had improved greatly. He had no further fever, the urine was passed without pain, he looked well, and the escape of pus from the umbilical fistula had ceased. Urine, however, continued to escape from the umbilicus as soon as the bladder contained an appreciable amount of fluid.
On account of the gonococcus infection it was felt wiser not to leave in a perma
~~Hind, \V.: Diseases of the Urachus and Umbilicus. Brit. Med. Jour., 1902, ii, 242.~~
t 111, Edward J.: Amer. Jour. Obst., 1897, xxxvi, 568.
X Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1893, lvii, 73.

URACHAL CAVITIES AND INFECTIONS. 593
nent catheter. The abdominal walls were not so painful on pressure, and one could now make out a hard cord, the thickness of a finger, in the mid-line, extending from the umbilicus to the bladder. After the cystitis had subsided, closure of the umbilical fistula was considered. As it was impossible to introduce a sound far, an excision of the upper portion of the cord was undertaken. The umbilicus was dissected free, and the fistulous tract about 2 cm. below this point was opened. Here there was a small lumen into which a sound could be introduced without difficulty and carried toward the bladder region. The farther dissection of the cord was easily accomplished without injury to the peritoneum. Midway between the umbilicus and symphysis, however, it was impossible to avoid entering the abdominal cavity. From the opening in the peritoneum one could see the relation of the bladder very well. This cord spread out and passed without any definite margin gradually into the upper portion of the bladder, just as is the case in the embryo. Care was taken not to injure the general peritoneal cavity. The urachus was freed to the point where it entered the bladder. It was then cut across transversely, so that the entire tract from the umbilicus to the bladder was excised. A funnel-like opening, 1.5 cm. wide, was left in the bladder. Examination of the inner surface of the bladder showed that this organ was a long, thick-walled tube, similar to that noted in Bramann's case. The opening in the bladder was closed, and a drain laid into the incision. The wound had healed completely in four weeks.
At the end of two and a half years there was no evidence of any fistula, and the patient was completely cured, the only discomfort being frequent urination.
A Case of Patent Urachus Over One Inch in Diameter Forming a Tubular Prolongation of the Bladder. — Marshall* reports the case of a woman, aged forty-three, who had complete procidentia. On opening the abdomen to suspend the uterus, and while making a short incision midway between the pubes and umbilicus, he found the subperitoneal fat very abundant. On dividing this he could see what appeared to be peritoneum. A nick having been made into it, a pair of scissors was passed upward and then downward to enlarge the incision.
On lifting the retroflexed uterus up to the abdominal opening and thus compressing the bladder, Marshall noted an escape of some clear fluid into the lower part of the wound. This aroused his suspicions. A bougie introduced into the bladder through the urethra entered the abdominal incision through a large opening. What was at first thought to be peritoneum was in reality the anterior wall of a patent urachus. The first cut upward had slit through the upper blind end in the peritoneum into the abdominal cavity. The downward cut had opened the peritoneum and both walls of the urachus.
The urachal opening was V/i inches in diameter and formed a large opening in the conic-shaped bladder. The bladder was closed with a double layer of continuous catgut sutures and a catheter was kept in for one week. The patient made a good recovery.
Suppuration of the Persistent Urachus With Rupture into the Bladder and the Abdominal Wall.f — In November, 1901, a forty-eight-year-old man came to Mikulicz's clinic. He had had a gonococcal
~~Marshall: Jour, of Obst. and Gyn. of the Brit. Empire, 1907, xi, 259.~~
t Matthias, F. : Vereiterung des persistierenden Urachus mit Durchbruch in die Blase und in die Bauchdecken. Beitrage z. khn. Chir.; herausg. von Paul Bruns, Tubingen, 190-1, xlii, 339. 39

594 THE UMBILICUS AND ITS DISEASES.
infection ten years before, which had not been promptly treated. For the last few years he had had an abundant discharge from the urethra. Apart from this the patient had been well. Six months before admission, he began to have a pressure in the lower abdominal region and suffered from a general feeling of malaise. The urine was cloudy and contained whitish threads and flocculi. There was a cramp-like, sticking pain in the urethra. During the three months following this the patient lost weight and the urine was cloudy. Two months later there was again pain in the lower abdomen, and a tumor could be felt above the top of the bladder. Mikulicz found a firm, ill-defined tumor lying below the umbilicus. This occupied the mid-line and extended a little more to the right. It commenced three fingerbreadths below the umbilicus, and ended 5 cm. above the symphysis. There was a cord passing from the tumor to the umbilicus. The umbilicus itself appeared normal. , Mikulicz thought that he was dealing with an abscess of the abdominal wall, and one that communicated with the bladder, and that its origin was due to the extension of a cystitis by way of a persistent urachus. Bladder irrigations were employed. When there was a large quantity of pus in the urine, the tumor became smaller and the patient felt better. The reverse was the case when the urine contained but little pus. The difference in the size of the tumor was manifested in its transverse diameter. When a large amount of pus escaped in the urine and the tumor had diminished to half its volume, a cystoscopic examination was made. In the anterior bladder-wall, in the neighborhood of the top of the bladder and in the mid-line, was a transverse oval opening passing into a funnelshaped diverticulum. The walls of this could be seen for some distance, but the point ended in darkness.
Operation. — A median incision was made. The skin was dissected free from the tumor, which was covered with thick and edematous fascia, and on the left side the peritoneal cavity was opened. From this point the tumor was separated from the abdominal wall, and in the lower angle of the incision the bladder was recognized by means of a metal catheter which had been introduced from below. The tumor sat on the top of the bladder, and on the right and on the left, between the tumor and bladder, was a loop of small bowel which was separated without injury. The tumor was the size of a billiard ball, and sat as a cap on the top of the bladder. The muscular covering of the bladder extended over on it, particularly on the posterior surface. The peritoneal cavity was well walled off and the tumor opened. Its walls were 12 mm. thick, and the cavity was the size of a walnut. From it escaped an old clot mixed with pus. An attempt was made, by filling the bladder with 300 c.c. of salt solution, to find a communication with the abscess cavity. In this the operator was unsuccessful ; no fluid escaped, but a sound could be passed from the cavity into the bladder. The tumor was separated from the bladder. The small opening in the bladder-wall was closed with catgut, and the muscularis, which formed two flaps over the tumor, was brought together. A retention catheter was introduced into the bladder and kept in place for ten days. The urine then came away spontaneously, and the pus disappeared almost completely. The extirpated tumor was the size of an apple and irregularly round. Its walls varied from 2 to 20 mm. in thickness, and there were irregular dilatations in the interior. It consisted of striated, dense connective tissue. Here and there were citron-yellow portions, undoubtedly fatty tissue. The inner surface of the sac, apart from dilatations, was uneven; no mucosa was visible.

URACHAL CAVITIES AND INFECTIONS. 595
Microscopic Examination. — Sections showed that the wall was made up of smooth muscle-fibers, connective tissue, and an inner zone consisting of old connective tissue containing many round-cells and small blood-vessels. There were hemorrhages, and here and there the tissue was necrotic. There was no evidence of epithelium. Mikulicz found a small opening in the wall of the tumor. This was lined with epithelium. It could be traced for a distance of 2 mm. in serial sections, and had a breadth of 1 mm. The epithelium lining the canal was several layers thick; only in a few places did it consist of a single layer.
In conclusion Mikulicz said that very probably the normal dilatation of the opening of the urachus in the bladder, being funnel-shaped, had allowed the cystitis to extend to the urachus, and through breaking of the wall there had resulted abscess formation in the musculature of the bladder-wall and of the abdominal wall to the umbilicus. Since the abscess originally lay within the bladder musculature, its rupture into the interior of the bladder near the actual opening of the urachus was not exceptional.
[There is no doubt in this case that there was an abscess between the bladder and the umbilicus. It was probably of urachal origin, but Matthias's description is not particularly clear. — T. S. C]
Escape of a Calculus From the Umbilicus.* — This case had been reported by Gennaro in 1890. After a mucopurulent discharge from the umbilicus had lasted several days, a calculus escaped from the umbilical opening. It consisted of urate of soda, phosphate of lime, and magnesia. The urachus was a diverticulum of the bladder. Gennaro thought that the calculus was due to fermentation of the stagnant ammoniacal urine.
A Case of Dilated Urachus Accidentally Opened During an Abdominal Section for Peritonitis. Recovery. f — A boy, aged five, was brought to the Children's Hospital, Brighton, on February 18, 1896. There was a history of vomiting and diarrhea for two days. On admission he was suffering with severe abdominal pain, but there was no marked tenderness. His temperature was 102° F. The next day he was much worse, and lay on his left side, with his thighs fully flexed. The distention, tenderness, and pain were more severe. There was no localized swelling. His diarrhea was almost constant. His temperature was 103.6° F., his pulse, 108. In the next five days there was some improvement in his general condition. The abdomen was still distended, but the vomiting and diarrhea were improved. On the ninth day, in the region of the bladder and extending nearly to the umbilicus, there could be made out a certain amount of resistance that was fairly sharply defined. Micturition was frequent, but there was no dribbling. On the suspicion that the swelling might be the bladder, a catheter was passed, but only about half an ounce of urine was drawn off. This did not affect the size or position of the hypogastric fulness. On February 27th the general condition was better, except that he was passing a large quantity of mucus by bowel. The distention and hypogastric fulness were less marked. On the evening of the next day, twelve days after the first symptoms, the boy was much worse, his vomiting had returned, and the distention was
~~Monod, Jean: Des fistules urinaires ombilicales dues a. la persistance de l'ouraque. These~~
de Paris, 1899 (obs. 47), 168.
t Morgan, G.: The Lancet, 1896, ii, 1154.

596 THE UMBILICUS AND ITS DISEASES.
very severe. His temperature was 103° F. and his condition so critical that it was decided to operate at once.
An incision was made extending from the umbilicus to a point near the pubes. The deeper abdominal layers were divided carefully over a director. An incision was made into what was taken for the subperitoneal fat and peritoneum, and there was a gush of about one ounce of clear urine. The wound was at once clamped and a catheter was passed. The bladder was found to be quite empty and lying in the pelvis, but the catheter could be passed up into the wound in the cyst where the clamp was. After carefully dissecting around the cyst, Morgan opened the abdominal cavity and found signs of recent peritonitis, with flakes of lymph, but no pus. The abdominal cavity was flushed with hot water, and the intestines were carefully sponged. The boy was too ill to have a prolonged examination or have the mass dissected out, but it was certain that the cyst was in the mid-line, running up to the umbilicus and communicating with the bladder. After the bladder and cyst had been washed out with boric acid solution, the wound in the bladder was closed with a double row of silk sutures, the stitches not penetrating to the mucous membrane. The abdominal wall was also carefully closed. On the following day the boy was much better, but on the fourth day pus began to well up from the suture line. Three stitches were taken out and the pus cavity was irrigated. For ten days after this there was some escape of urine from the abdominal wound, but this became less and less, and the boy's general condition improved. Twentysix days after operation the wound was closed and the boy was quite well.
A Rare Variety of Cyst of the Urinary Bladder, Probably Arising From the Urachus, Cured by Operation.* — A. M'V., a miner, aged thirty-nine, was admitted to the Glasgow Royal Infirmary on October 21, 1895. He complained of severe pain in the hypogastric region. This had commenced four days before, and had continued ever since. Coincident with the onset of the pain he found that he was unable to micturate, and his doctor had to pass a catheter. When the urine was drawn off, it contained a large quantity of blood. Vomiting came on soon after the onset of the pain and was followed by attacks of diarrhea.
On admission he was suffering considerable pain, had an anxious expression and walked with difficulty. The skin over the region of the bladder was red and blistered from the use of hot fomentations and applications of mustard. The abdomen was considerably swollen, very tense over the region of the bladder, and from the umbilicus to the pubes it was absolutely dull on percussion. After admission a catheter was passed and 20 ounces of urine, containing a large quantity of blood, were drawn off. This gave the patient considerable relief, but even after the bladder had been completely emptied, the dulness in the hypogastric region did not disappear. From the 1st until the 8th of November the patient's condition steadily improved, and at the latter date he was able to pass his urine without difficulty. On examination the abdomen still showed a considerable amount of swelling in the hypogastric region. The swelling in appearance greatly resembled a distended bladder.
Operation. — A free incision was made in the mid-line, midway between the pubes
~~Newman, D.: Throe Renal Cases, a Case of Cyst of the Urachus, and a Case of Strangulated Hernia, Treated in the Surgical Wards of the Glasgow Royal Infirmary. Glasgow Med.~~
Jour., 1896, xlvi, 20.

URACHAL CAVITIES AND INFECTIONS. 597
and the umbilicus. On incision into the transversalis fascia, a large quantity of gelatinous fluid escaped which had a strongly ammoniacal odor. The cyst-wall was thin and smooth, and its anterior wall was not covered with peritoneum. The cyst extended from the apex of the bladder to the umbilicus. After evacuation of the contents the cyst was washed out with carbolic acid solution, and a drainagetube inserted. In the evening the dressing was found to be soiled with urine which had a strongly ammoniacal odor.
On November 16th the greater part of the urine was passing through the abdominal wound and a retention catheter was now introduced into the urethra. Notwithstanding this the urine continued to escape from the wound, and not until December 16th did the cyst become completely obliterated and the wound in the abdomen close. On careful inquiry into the history of the patient it was found that he had noticed a swelling in the hypogastric region as long as he could remember, but until this occasion it had never given him any trouble.
Probably a Partially Patent Urachus with Infection.* — This patient was observed by Chopart. She was pregnant, and had suffered from retention of urine for some time. The abdomen became tender and painful. Fluctuation was felt, and was specially marked in the region of the umbilicus. An incision was made between the right rectus muscle and the umbilicus, and much pus escaped. On the following clay the bed and the apparel of the patient were soaked with urine. This escaped for some time by the umbilicus until, after repeated catheterization, the urine commenced to pass through the urethra and the umbilicus closed.
Dilatation of the Urachus; Communication with the Bladder. — Patel'sf patient was a child three years of age who, from birth, had incontinence of urine both day and night. The urine did not escape drop by drop, but at frequent intervals and involuntarily. There were no malformations.
Below the umbilicus was a voluminous tumefaction, fusiform, and prominent in its central portion. In its middle portion it was the size of two fists. It was exactly in the median line; above it reached the umbilicus, and below passed into the pelvis, although its termination could not be felt. It was movable. Catheterization yielded a small glass of clear urine. There was evidently a tumor lying behind the abdominal walls, adherent to the umbilicus, and clinically independent of the bladder.
A median incision was made below the umbilicus. The tumor was found adherent to the umbilicus. Half a liter of pale-yellow fluid escaped, which contained large quantities of albumin. The sac was lined with an irregularly wrinkled muscular layer. Above the finger impinged on the umbilicus. The inferior end was very narrow and was dilated with difficulty. It led to a small circular cavity in which the vesical trigonum was recognized. Removal of the diverticulum was not undertaken on account of the size of the tumor and of its probable adhesion to the peritoneum, and on account of the patient's age. The walls of the sac were sutured much in the way that cavities resulting from removal of hydatids of the liver are obliterated. The walls were brought together and a catheter was left in the blad
~~Xicaise: Ombilic. Diet, encycloped. des sci. med., Paris, 1881, 2. ser., xv, 140.~~
| Patel: Malformation congenitale de 1'ouraque. Dilatation kystique de la partie interieure de 1'ouraque demeure en communication avec la vessie; incontinence d'urine symptornatique. Capitonnage de la poche. Rev. mens, des maladies de l'enfance, Paris, 1904, xxii, 77.

598

THE UMBILICUS AND ITS DISEASES.

der. During the five days that the catheter remained in place there was some discharge from the abdominal wall. When the child left the hospital, the abdomen was soft. The bladder was large enough and the child urinated about every three hours. There was no incontinence. Recovery was permanent. This case was also reported by Gabriel Renard.*
The Diagnosis and Treatment of a Case of Patent Urachus. f — The patient was a woman twenty-five years of age. Six months previously she had begun to have pain in the umbilical region. Two weeks later a swelling had appeared at the umbilicus. This had ruptured, and since then pus had been discharging, except during occasional intervals of a week. A probe was
passed through the umbilicus into the bladder, and the end emerged at the external urinary meatus.
The urachus was opened on a director about two inches above the symphysis. It showed a dilatation in the middle, with a constriction above, and below, where it connected with the bladder. The actual cautery was used to destroy about one inch of the lower portion of the urachus. The portion above was packed, a piece of iodoform gauze being passed through the fistula to the umbilicus. The bladder was accidentally opened, but at once closed with catgut. The patient made a good recovery.
Urachal Cyst Communicating with the Bladder. — Robinson+ says: " I worked several years in the dissecting room, paying special attention to visceral and pelvic anatomy, but did not see any urachal cyst in but one autopsy (Fig. 251)." In this case the urachus was dilated, forming a fusiform tumor. It opened into the bladder and extended upward as far as the umbilicus. . . . "I understand from veterinarians that the horse is one of the most typical animals to show urachal cysts, and that quite late in horse fetal life the urachus is found often quite a distance above the bladder."
A Urachal Cyst Communicating With the Bladder. — In Roser's § case the urachal cyst had a small opening into the bladder (Fig. 252) . When the patient wished to void, the contraction of the bladder muscles forced the
~~Etenard, Gabriel: Sur un kyste de l'ouraque. These de Lyon, 1905, No. 89.~~
fReid, \Y. L.: Glasgow Hosp. Reports, 1899, ii, 76. % Robinson, F. Byron: Annals of Surg., 1891, xiv, 336.
§ Roser, W '.: Ueber Operation der Urachuscysten. Langenbeck's Arch. f. klin. Chir., 1877, xx, 47:;.

Fig. 251. — A Dilated Urachus Communicating With the Bladder. (After F. Byron Robinson.) The urachus (6) is patent from the bladder (a) almost to the umbilicus. It is markedly dilated, and its cavity communicates directly with the bladder. It resembles a secondary bladder.

URACHAL CAVITIES AND INFECTIONS.

599

urine into the cyst more easily than through the urethra. The cyst, therefore, became more and more distended, until three or four liters of urine accumulated. When it was desired to empty the bladder, a catheter had to be introduced into it and the cyst was then pressed upon. In order to keep the patient free from trouble catheterization several times a day was necessary.
The patient had what appeared to be a greatly distended bladder when she was three months pregnant. A puncture was made in the linea alba above, and a large amount of urine removed. The pregnancy went to term. Four years later she had a similar attack when she was again pregnant. The old cyst had refilled. It was tapped from above, and the patient miscarried. The cyst again filled, and operation became necessary. The urine was ammoniacal, owing to stasis in the sac. There was foul urine in the cyst, which at that time had reached the umbilicus.
An extraperitoneal opening, about 3 cm. long, was made in the mid-line, and two chambers full of stinking ammoniacal purulent fluid escaped. There was temporary relief. A retention catheter failed to bring about closure of the bladder, and when last seen, the patient still had the urachal cyst opening into the bladder.
Polypus of the Urinary Bladder with the Development of a Urinary Fistula at the Umbilicus. — ■ Savory's* patient was a male, thirteen months old and sickly. Immediately beneath and partly surrounding the umbilicus was a firm, tense swelling, two or three inches in diameter. Its limits were not well defined. It was very tender, and pain was increased by attempts to void. The urine merely dribbled away. The child had been ill eight weeks. The first thing noticed was that micturition caused pain in the lower abdomen, followed by an almost constant desire to void rupted temporarily and then started again.
The umbilical induration was incised and pus escaped; later urine appeared, and nearly all came this way Autopsy. — On section of the abdomen an abscess was found between the posterior surface of the abdominal parietes and the peritoneum and extending from the umbilicus almost to the symphysis. The omentum was adherent to the abdominal wall. The growth in the bladder stretched across behind the ureteral orifices, which were dilated. This mass was attached at each side, but was free in the center, and could block the urethra. It was a polyp. It was impossible to find the opening between the bladder and the abscess by which the urine escaped from the umbilicus.
A Partially Patent Urachus.t — Simon reports the case of a
~~Savory, W. S.: Med. Times, London, 1852, N. S., v, 106.~~
t Simon, Charles: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. SO (obs. 12), 26.

Fig. 252. — Urachal Cyst. (Redrawn by August Horn after W. Roser.) The bladder itself looks normal, except that at the upper part anteriorly there is a small opening which communicates with a large cyst extending as high as the umbilicus.

The stream was often inter

600 THE UMBILICUS AND ITS DISEASES.
patient of Portal, a man forty-five years of age, who died shortly after a fall on the abdomen resulting in a severe injur}' to the bladder. Some time after the accident he had noticed that the urine was escaping at the umbilicus. Portal says: "On opening the bod}' I found a tube which extended from the umbilicus to the bladder. This was cone-shaped. Its diameter toward the umbilicus was ^4 inch and 1^2 inches at the bladder. The thickness was unequal. The volume of the bladder did not exceed that of a small apple."
An Infected Urachal Cyst Communicating With the Bladder.* — This patient, a man sixty-six years of age, came under Trendelenburg's observation on July 3, 1887. For a year or more he had had frequent urination. The urine was cloudy, and often much pressure was necessary to start it. Six months before he had noticed a swelling in the lower abdomen, above the symphysis. For three or four days he had had pain in this region, and soon after a spontaneous opening had appeared at the umbilicus from which a purulent fluid had escaped. Recently he had become weaker.
On admission to the hospital he showed, in the hypogastric region, a marked swelling about the size of a head. This began just above the symphysis and reached to the umbilicus. Rectal examination revealed an enlarged prostate, especially on the right, and above this a distended bladder. A very fine sound was passed from the umbilicus and entered into a large cavity. The fluid from the umbilicus showed round-cells undergoing fatty change. After catheterization with the removal of 1500 c.c. of cloudy urine the swelling to a large extent disappeared, but there persisted a long tumor reaching from the umbilicus to the symphysis.
Operation. — An incision was made between the umbilicus and the symphysis. Immediately behind the fascia was a sac containing about a liter of urine mixed with pus. A piece of the wall was removed, and the wound closed with drainage. A purulent fluid continued to escape from the sac. Microscopic examination of the wall showed it to be lined with one layer of squamous epithelium resembling that of the bladder. There was no muscle in the wall. The connective tissue contained many round-cells.
A Dilated Urachus Communicating With the Bladder . f — The patient was a very frail woman, weighing probably 85 pounds. At labor she had had a bad tear and developed a fever, from 100° to 101.5° F., for nearly six weeks. In the following spring she entered the hospital for operation, but later developed pain and swelling in the right side.
A median incision, 2^ inches long, was made. The peritoneum was exposed and cut, but the bladder was opened. The patient had just voided before the operation. The wound was closed, but the operator, in attempting to enter the peritoneum, got into the same cavity again. It proved to be an accessory bladder — really a dilated urachus — and contained l}/£ to 2 pints of urine. A catheter introduced into the urethra could be passed into this cavity. It was closed and the patient recovered.
Escape of Urine From the Umbilicus. — UnterbergerJ reporter! the case of a woman, twenty-three years of age. She was supposed to have
Schnellenbach: [Jeber die (Jrachuscysten. Inaug. Diss., Bonn, 1888. f Timmerman, C. F.: Trans. Med. Soc. State of New York, 1904, 331.
tTJnterberger: Retroversio-flexio uteri gravidi partialis incarcerata. Urachus-fistel. Monatssohr. f. Geb. u. Gyn., 1900, xi, 657.

URACHAL CAVITIES AND INFECTIONS. 601
had an ovarian cyst that had ruptured through the umbilicus, and for three weeks clear fluid had continued to escape from the navel.
The trouble had begun with pain in the lower abdomen. This had become so severe that the patient had been forced to remain in bed and local applications had been applied. Urination and defecation at this time were normal.
The patient had fever and gradually became weaker. One month before her admission to the hospital urinary disturbances developed, and after a time the urine commenced to escape through the umbilicus and the pain disappeared. Pus sometimes escaped from the umbilicus with the urine.
For fourteen days before the patient entered the hospital no urine had been passed from the urethra. The umbilical opening had the caliber of a hair, and was surrounded by a small red zone. The abdominal walls were somewhat infiltrated. A catheter passed into the bladder entered for its entire length and about 2000 c.c. of urine mixed with pus were removed. The uterus, which contained a pregnancy, was retroverted and partially incarcerated. No operation was performed, but Unterberger regarded the case as one of patent urachus.
A Dilated and Infected Urachus Communicating With the Bladder and Umbilicus.* — A. W., white, male, aged forty, was admitted to the Georgetown University Hospital, June 21, 1904. When twenty years old he had gonorrhea, from which he made a good recovery. His present trouble began when he was seventeen years of age, with pain in the suprapubic region extending to the umbilicus. There was induration and tenderness of the parts on pressure. These symptoms grew worse; poultices were applied, and two weeks later an opening appeared at the umbilicus through which was discharged a moderate amount of pus. From this time the fistula remained patulous almost constantly, with a discharge of pus and urine. Occasionally it would close — never longer than for two days, during which time there would be considerable pain, especially on urination. When the opening closed, the area around and below the navel would become inflamed, and when it was reestablished, spontaneously or by the patient, there would be immediate relief from pain and the escape of a large quantity of dark, offensive-smelling fluid. The odor was worse after the fistula had been closed a day or two than when it was discharging freely, but at all times it was offensive, to a great extent barring the patient from the society of his friends. The discharge had always been most profuse during urination, and in the morning, when the patient would begin to move about, but there was at all times enough to keep his clothing soiled. At thirty-four years of age he had an attack of pain in the region of the right kidney, with nausea, vomiting, and elevation of temperature, and he had to keep to his bed for three weeks. Since then he had had other attacks of less severity, usually beginning with pain in the loin and extending to the testicle, sometimes accompanied by vomiting and the passage of blood through the urethra. The attacks had always been most severe after exertion.
Examination showed a large, robust, well-nourished man, with good color and apparently in excellent health. At the umbilicus was a flat area of scar tissue of a bluish color, containing a small opening through which a probe could be passed
~~Vaughan, George T. : Patent Urachus. Review of the Cases Reported. Operation on a~~
Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus. Trans. Amer. Surg. Assoc, 1905, xxiii, 273.

602 THE UMBILICUS AND ITS DISEASES.
downward and slightly backward for a distance of three and one-half inches into a pouch which lay in front of the bladder.
The urine from the bladder contained urates and epithelial cells. A diagnosis of patent urachus with dilatation into a pouch and infection of its contents was made, and operation was advised.
Operation (June 25, 1904). — The bladder was distended with water through the urethra, and a grooved director was passed through the umbilical fistula to the bottom. The cavity was opened, and a considerable amount of bloody pus, with an offensive urinary odor, was evacuated. The sac was pyriform in shape, with the small end above: it lay in front of the peritoneum, and above and in front of the bladder, with which it communicated through a very small opening. The sac was about three inches in length, and had a capacity of about three ounces; it contained many laminated clots and resembled very much a small urinary bladder, the walls containing muscular and fibrous tissue and being lined with mucous membrane. The sac was carefully dissected out, the peritoneum being opened in two places accidentally, and the walls were brought together. Recovery was without incident except for the high temperature that occurred on the day after operation (107° F. in the axilla), and he was well three weeks after the operation.
On August 13, 1904, just a month after leaving the hospital, the patient had a severe attack of renal colic on the right side, with chills, vomiting, blood}^ urine, dehrium, and swelling of the face and extremities. His pulse was 140, the temperature 104° F. On August 21st the right kidney was incised, and a round stone, half an inch in diameter, was removed. After this the patient had no further trouble until February, 1905, when he had an attack of renal colic on the left side, with the passage of several small, pea-sized calculi from the bladder. A month later he had another attack, which was much more severe and was complicated with almost complete suppression of urine for forty-eight hours, delirium, chills, and a temperature of 106° F. On May 1, 1905, the left kidney was incised and two stones were removed. Up to June 27, 1905, the patient had had no further trouble with his bladder, but had had an attack of appendicitis which he managed to pass through without operation.
Under date of May 12, 1915, Dr. Vaughan writes: "After an operation on both kidneys for stone the patient got along pretty well until December 6, 1906, when I had to operate on the left kidney again, removing a large oval stone. Patient recovered, but had trouble again during the summer of 1914 (during my absence), and Dr. Fowler removed stones from the right kidney. He is in pretty good condition now, but evidently has stones, probably in both kidneys. Since June 25, 1904, patient has had five operations — excision of urachus and two operations on each kidney.'"
Suppuration of a Urachal Cyst. — In Weiser's* Case 3 the patient was a man aged seventy-three, who had always been well except for an attack of orchitis four months before the present sickness. For six months he had suffered with pain and soreness in the abdomen, but had noticed no tumor. Two weeks before Weiser's visit the abdominal wall had opened spontaneously two inches below the umbilicus, and discharged urine. There had never been any pus. When the patient was lying down quietly, the urine did not escape, but as soon as he assumed an upright position, there was a constant discharge. The old gentleman
~~Weiser, W. R.: Annals of Surg., 1906, xliv, 529.~~

URACHAL CAVITIES AND INFECTIONS.

603

OOTteo LINE REPRESENTS UVACHUS *-* CYST WALLS

appeared perfectly well aside from this urinary sinus, which in caliber was about
the size of a pencil, and entered immediately into a large sac, the lower limit
of which Weiser could not reach with an eightinch probe.
Weiser entered the peritoneal cavity above the
sinus, and found the sac anterior to the parietal
peritoneum. The sac extended to within one inch
of the umbilicus, above which the urachus was not
patulous (Fig. 253), and downward into the pelvis.
It was intimately connected with the bladder at the
point of urachal attachment, and was densely adherent to the posterior bladder-wall as well as to
the intestines, the greater part of the sac being made
up of abdominal viscera. After freeing the anterior
wall of the cyst sufficiently, he made a plastic closure
of the original point of rupture through the abdominal wall. A catheter was placed in the bladder through the urethra and allowed to remain for several days. The abdominal wound was closed without drainage. The patient made a good recovery, and was about the house on the fourteenth
day. Two months later Dr. Stowell, under whose care the patient had been originally, told Dr. Weiser that the abdominal wall had given way again a trifle lower down toward the symphysis, and urine was again discharging through a small sinus. Later the opening closed spontaneously.
A Very Large Abscess-sac Extending into the Pelvis, Opening a t t h e Umbilicus, and Containing a Calculus. — This case in many respects suggests an umbilical abscess that reaches very large proportions and contains a concretion. On the other hand, it makes one think of certain cases of abscess of the urachus. I wrote Dr. Weiser* as to the character of the calculus. From his reply it was evidently of urinary origin, and probably made up largely of oxalates. A woman, seventy-five years of age, had for fifteen years suffered inconvenience
from a discharge of pus from the umbilicus. The discharge was constant and at
~~Weiser, W. R.: Annals of Surg., 1906, xliv, 531.~~

Fig. 253. — Urachal Cyst. (After W. R. Weiser, Case 3, Fig. 3.) Male, aged seventy-three. The abdominal wall opened spontaneously two inches below the umbilicus and urine was discharged. The sac extended upward to within an inch of the umbilicus ; downward into the pelvis. It was intimately attached to the fundus of the bladder.

Fig. 254.

(After

-Urachal Cyst. W. R. Weiser.)
Revised from Case 1. At the operation Weiser tapped the cyst, evacuating five ounces of horribly fetid pus, followed by a calculus weighing 70 grains. The cyst had a thick and indurated wall and dipped well down into the pelvis. It was extraperitoneal. [Dr. Weiser tells me that in his article two of his pictures were not properly placed, hence the "revision."— T. S. C.l

604 THE UMBILICUS AXD ITS DISEASES.
times profuse. At various times she had consulted a physician in reference to the condition, but, aside from prescribing various washes and ointments, no treatment or diagnosis was offered.
She finally consulted Dr. Weiser. The patient at this time was well nourished and active for her age. The abdomen was very fat, and a tumor the size of a cocoanut presented in the median line, between the umbilicus and the symphysis. The mass could be raised with the abdominal wall and was apparently attached thereto.
There was a copious discharge of foul-smelling pus from the umbilicus, and an eight-inch probe, passed into the sinus, failed to reach the lower wall of the sac. The temperature was 101° F., her pulse, 100. She volunteered the information that the condition was no worse than usual, but that she was not feeling well generally, and during the past month there had been very frequent micturition.
Under ether Weiser excised the umbilicus and unhealthy skin surrounding it, and cutting down through two inches of fat, came upon a bulging mass extending from the umbilicus as far down as he could feel toward the symphysis (Fig. 254). This he tapped, and evacuated about five ounces of horribly fetid pus, followed by a calculus weighing 70 grains. Exploration with the finger demonstrated the fact that the cyst had a thick and indurated wall, and dipped well down into the pelvis. Up to this point in the operation he had not opened the peritoneal cavity. He now washed out the sac. packed it with gauze, and entered the peritoneal cavity, above the location of the tumor. To his surprise he found the mass densely adherent to the intestine posteriorly, and on passing his hand down into the pelvis on the outside of the cyst, discovered it to be closely associated with the bladder. He now concluded that he was dealing with a urachal cyst, and, as the posterior wall was almost entirely made up of intestines, he concluded to cut away such portions of the sac as seemed safe. He left the posterior wall intact, as well as that portion which dipped down into the pelvis. The wound was closed as- far as the peritoneum, and the rest was walled off with a coffer-dam drain of iodoform gauze. Her recovery was uneventful, but it required three months for the sinus to close.
March 11, 1912. My Dear Dr. Cullen: Replying to your letter of the eighth inst. and referring to the urachal calculus: The stone was quite hard, and the surface was dark brown, resembling in color a type of gall-stone. Upon cutting open, the substance of the stone resembled a hard bladder stone in color and general appearance.
Unfortunately, this stone was lost before reaching the laboratory, but I think it was probably made up largely of oxalates. My opinion was that this was a urinary calculus which became discolored on its outer strata by lying in a bed of foul pus and being exposed through the discharging sinus at the umbilicus.
Cordially yours,
Walter R. Weiser.
Case of Vesico-umbilical Fistula of FourteenYears' Standing. — Wbrster* reports the case of Miss H., aged twenty-one. She had good health until a severe attack of diphtheria when eight years old. Following this she had incontinence of urine and cystitis. From about this time she could not straighten herself up properly and had a habit of standing with the body bent forward at an angle of 45 degrees. She was also incapable of stooping to pick up any
~~Worster, Joseph: Med. Record, 1877, xii, 196.~~

URACHAL CAVITIES AND INFECTIONS. 605
thing. Two years after the diphtheria she suffered from a cystitis, accompanied by a copious flow of purulent matter from the urethra, and shortly afterward a swelling was noted in the umbilical region, the appearance of which was followed by large and repeated discharges of pus from the umbilical opening, and subsequently of urineThe umbilical inflammation subsided, but pus escaped from time to time, and the urine continually. In her eleventh year, as a result of a contusion, an opening occurred below the umbilicus, from which urine escaped. Extending from the bladder to the umbilicus was a hard, cord-like mass, two inches in diameter and uniform in size.
Operation (April 14, 1875). — Two elliptic incisions were made and the umbilical area removed. Eight days after the operation urine escaped from the wound. A second operation was undertaken at once, with good results.

LITERATURE CONSULTED ON URACHAL CAVITIES COMMUNICATING WITH THE BLADDER OR UMBILICUS OR WITH BOTH.
Ball, C. B. : A Case of Pervious Urachus with Remarkable Disease of Bladder. Trans. Acad.
Med. Ireland, 1883-84, Dublin, 1884, ii, 376. Bourgeois: Jour. gen. de med., 1821, lxxvi, 219. Bramann, F. : Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., 1887,
xxxvi, 996. Freer, J. A. : Abnormalities of the Urachus. Annals of Surg., 1887, v, 107. Garrigues, H. J.: Persistent Urachus in an Adult Woman. Med. Record, New York, 1899, lvi,
720. Graf, F. : Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896. Hastings, C: A Singular Case of Ischuria. London Med. and Phys. Jour., 1829, N. S., vi,
515. Hind, W. : Diseases of the Urachus and Umbilicus. Brit. Med. Jour., 1902, ii, 242. Ill, E. J.: Tumors of the Urachus. Trans. Amer. Assoc. Obst. and Gyn., 1892, v, 238. Amer.
Jour. Obst., 1897, xxxvi, 568. Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. Marshall, G. B. : Case of Patent Urachus over One Inch in diameter, forming a Tubular Prolongation of the Bladder. Jour. Obst. and Gyn. of the Brit. Empire, 1907, xi, 259. Matthias, F. : Vereiterung des persistierenden Urachus mit Durchbruch in die Blase und in die
Bauchdecken. Beitriige z. klin. Chir.; herausg. von Paul Bruns, Tubingen, 1904, xlii, 339. Monod, J. : Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,
1899, No. 62. Morgan, G. : A Case of Dilated Urachus Accidentally Opened Whilst Performing Abdominal
Section for Peritonitis; Recovery. The Lancet, 1896, ii, 1154. Newman, D.: Three Renal Cases, a Case of Cyst of the Urachus, and a Case of Strangulated
Hernia, Treated in the Surgical Wards of the Glasgow Royal Infirmary. Glasgow Med.
Jour., 1896, xlvi, 20. Nicaise: Ombilic. Diet, encycloped. des sci. med., Paris, 1881, 2. ser., xv, 140. Patel, M.: Malformation congenitale de l'ouraque; dilatation kystique de la partie interieure de
l'ouraque demeure en communication avec la vessie; incontinence d'urine symptomatique.
Capitonnage de la poche. Rev. mensuelle des mal. de l'enfance, Paris, 1904, xxii, 77. Reid, W. L.: On the Diagnosis and Treatment of a Case of Patent Urachus. Glasgow Hosp.
Rep., 1899, ii, 76. Renard, Gabriel: Sur un kyste de l'ouraque. These de Lyon, 1905, No. 89. Robinson, F. B.: Cysts of the Urachus (Congenital Cysts, Extraperitoneal Cysts, or Dilatation
of Functionless Ducts). Annals of Surg., 1891, xiv, 336. Roser, W.: Ueber Operation der Urachuscysten. Langenbeck's Arch. f. klin. Chir., 1877, xx,
473. Savory, W. S.: Polypus of the Urinary Bladder. Med. Times, London, 1852, N. S., v, 106.

606 THE UMBILICUS AND ITS DISEASES.
Schnellenbach: TJeber die Urachuscysten. Inaug. Diss., Bonn, 1888.
Simon, C: Quels sont les phenoinenes et le traitement des fistules urinaires ombilicales? These de Paris, 1843, No. 80.
Timnierman, C. F. : Dilated Urachus. Trans. Med. Soc. State of New York, 1904, 331.
Unterberger: Retro versio-flexio uteri gravidi partialis incarcerata. Urachus-fistel. Monatsschr. f. Geb. u. Gyn., 1900, xi, 657.
Vaughan, G. T.: Patent Urachus. Review of the Cases Reported. Operation on a Case Complicated with Stones in the Kidneys. A Note on Tumors and Cysts of the Urachus. Trans. Arner. Surg. Assoc, 1905, xxiii, 273.
Weiser, W. R. : Cysts of the Urachus. Annals of Surg., 1906, xliv, 529.
Worster, J.: Case of Vesico-abdominal Fistula of Fourteen Years' Standing. Med. Record, 1877, xii, 196.

CHAPTER XXXV. ACQUIRED URINARY FISTULA AT THE UMBILICUS.
General consideration.
Acquired umbilical urinary fistula, when no urethral obstruction exists.
Umbilical urinary fistula following partial or complete blockage of the urethra.
Urinary fistula at the umbilicus, with absence of the urethra.
Congenital phimosis, with a urinary umbilical fistula.
Umbilical urinary fistula following stricture of the urethra.
Umbilical urinary fistula associated with a growth in the bladder.
Vesical calculi obstructing the urethra and associated with escape of urine from the umbilicus;
report of cases. Umbilical urinary fistula associated with an enlarged prostate; report of cases. Apparent escape of urine from the umbilicus, the breasts, and other parts of the body.
We have already considered (p. 487) congenital umbilical urinary fistulse due to a patent urachus, and also fistulse resulting from the opening of a urachal sac (p. 578). We shall now discuss acquired umbilical urinary fistulse, occurring apparently independently of urachal cyst formation.
These cases naturally fall into two classes :
1. Umbilical urinary fistulse when no urethral obstruction exists.
2. Umbilical urinary fistulse associated with partial or complete blockage of the urethra.
Monod, in his splendid thesis on Umbilical Urinary Fistulse Due to Persistence of the Urachus, mentions a case recorded by Laurentius in 1600. A young woman had retention of urine for several days; this was followed by an escape of urine from the umbilicus. He also refers to an observation published by Fernel in 1638. A man, thirty years old, developed an umbilical urinary fistula following an obstruction at the neck of the bladder. In the same thesis reference is made to a case recorded by Peyer in 1721, in which, following retention of urine, a calculus escaped from the umbilicus. Scattered throughout the literature are isolated cases of acquired urinary umbilical fistulse.
We have seen (p. 515) that remnants of the urachus are by no means rare. The urachus may remain as a small, patent filament connected with the bladder. In other cases the urachus at the bladder has been obliterated, but here and there along its course are small, spindle-like dilatations. In after-life these small bays or lakes may become connected up so that finally there is produced a fistulous tract between the bladder and umbilicus. Where there is obstruction of the urethra, it is only natural that the old channel through the urachus should open, but in those cases in which the urethra is of normal caliber, the reason for the reestablishment of the urachal channel is more difficult to explain, unless the urachus has always been patent or unless there has been an inflammatory reaction in the urachal region.
607

608 THE UMBILICUS AND ITS DISEASES.

ACQUIRED UMBILICAL URINARY FISTULA WHEN NO URETHRAL OBSTRUCTION
EXISTS.
In none of the cases here recorded was any abnormality noted at the umbilicus at birth. Five of the patients were males and one was a female. The youngest was a small boy; the oldest, eighty. In all the cases the urine escaped from both the umbilicus and the urethra. The recognition of the condition was eas3 r on account of the escape of urine from the umbilicus. In Binnie's case there was a line of induration between the symphysis and umbilicus. In Leveque-Lasource's case the eightyyear-old patient had been passing his urine at intervals from the umbilicus for twenty-five years. In this case the possibility of an enlarged prostate cannot be excluded.
Florentin thought his patient had a urinary fistula at the umbilicus. The history, however, is not very conclusive.
A Partially Patent Urachus That Finally Opened at the Umbilicus, Causing a Urinary Fistula. — Binnie,* in 1905, saw a woman twenty-nine years of age who for six years was supposed to have had cystitis of unknown origin. All her life she had complained of pain and tenderness in the hypogastrium, and Binnie found a line of induration between the bladder and umbilicus. Pus was escaping from the umbilicus. A little mass of granulation tissue was present at the umbilicus, and through this Binnie could pass a probe into the bladder. He excised the fistula, which was so closely attached to the peritoneum that the abdomen had to be opened. The fistula led into a small diverticulum at the fundus of the bladder.
On histologic examination the walls were found to consist of very vascular granulation tissue, together with sclerosed tissue. The lumen was lined with necrotic material. No epithelium was observed.
A Urinary Umbilical Fistula.! — ■ The man was thirty years old. The urine escaped in jets from the umbilicus, but some of it was passed through the urethra.
Possibly a Urinary Fistula at the Umbilicus. — Florentine reports a case narrated to him by Professor Froelich. A small boy, two years of age, was examined at the hospital of Nancy in January, 1906. At the umbilicus was a tumor the size of a gooseberry or currant. It had not increased in size. In the beginning there had been no discharge, but after several months a purulent fluid had commenced to escape in moderate amount from a small ulceration situated at the margin of the elevation, and still persisted. On examination there was seen at the base of the umbilical cicatrix a small, reddish tumor attached to the skin by a broad, short pedicle, from the base of which a little drop of pus was being discharged. The tumor was irreducible. There was a small ulceration with violet margins. In the center was a small depression, into which a probe could be introduced for 3 cm.
Operation. — The tumor was continuous with a fibrous cord, which extended down the median line. It was dissected out and tied off, the outer portion being removed. Healing took place. No microscopic examination was made. Floren
~~Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc., 1908, ii, 109.~~
t Civiale, Jean: Traite de 1' affect ion calculeuse, Paris, 1838, 261.
t Florentin, P. : Fongus de l'ombilic chez le nouveau-ne et chez l'enfant. These de Nancy, 1908-09, No. 22 (obs. 8), 108.

ACQUIRED URINARY FISTULA AT THE UMBILICUS. 609
tin diagnosed the condition as a urinary fistula, but the case would seem to be doubtful.
Escape of Urine From the Umbilicus in an Old Man, * — The patient was a farmer, eighty years of age, of stout build. He had a double inguinal hernia. He had also had for a long period an umbilical hernia, which was not larger than a chestnut. For twenty-five years at times the urine had passed from the umbilicus, and sometimes from the urethra. It did not escape as a jet, as the opening was too small, but there was enough urine to keep the clothes wet. Xo method of control had thus far been discovered. Leveque-Lasource said that the condition was due to the reopening of the urachus.
A Case of Fistula of the Urachus. f — The patient was a soldier in active service, and had always been free from discomfort except that the pressure of the belt of his sword on the full bladder caused urine to escape from the umbilicus. At the umbilicus the opening was no larger than a hair in caliber, and even with a full bladder only a small amount of urine escaped. He was given a small quantity of potassium iodid and the urine soon contained an appreciable amount of iodin. The reaction was obtained from the umbilical urine by adding calomel, which at once gave it an intense yellow color.
A Vesico-umbilical Fistula. ± — -A boy, aged nine, had had incontinence of urine, and from time to time had complained of pain in the lower abdomen. For about six weeks urination had been frequent, and, three weeks before Trogneux saw him, moisture had been noted at the umbilicus, and later a few drops of urine had passed from the navel. The urine escaped both by the urethra and the umbilicus. Sometimes a large quantity came away from the navel, especially when the patient moved. The umbilical orifice was oval, elongated transversely, and the urine escaped from the bottom. The urethra was permeable. The bladder held 20 c.c. of fluid, and when more was introduced, it at once escaped by the umbilicus. The same result was obtained in the reverse direction. The urine contained pus.
Operation. — The tract was dissected out for 2 cm. and tied off. The upper part of the wound was closed. The canal was lined with what seemed to be macerated skin. On the tenth day the urine infiltrated the abdominal wall and escaped. The boy had tuberculosis in the apices of both lungs and was supposed to have tuberculosis of the bladder.
In this case the urachus did not open until the ninth year. The presence of the cystitis naturally hindered efforts at rectifying the condition.

UMBILICAL URINARY FISTULA FOLLOWING PARTIAL OR COMPLETE BLOCKAGE OF
THE URETHRA.
Although in the majority of the cases the definite type of obstruction to the escape of urine from the urethra has been stated, in a few cases it is merely recorded that an obstruction existed.
Monod refers to an observation made b} T Fernel in 1638. A man, aged thirty,
~~Leveque-Lasource: D'un cas particulier ou les urines sortaient par l'ombilic. Jour, de~~
med., Paris, 1811, xxi, 121.
t Starcke: Deutsche militararztliche Zeitschr., 1883, xii, 211.
% Trogneux, Albert: Contribution a l'etude des fistules ombilico-vesicales. These de Paris, 1897, No. 129. 40

610 THE UMBILICUS AND ITS DISEASES.
developed an umbilical urinary fistula following an obstruction at the neck of the bladder.
Littre* reported the case of a boy twelve years of age who had passed nearly all his urine by the umbilicus. At autopsy an obstruction was found at the neck of the bladder and the urachus had remained as a patent canal. Littre, in the same article, says that he knew a man thirty years old from whom the urine escaped forcibly from the umbilicus, no doubt as the result of an obstruction at the neck of the bladder.
Simon (obs. 14) records a case reported by Chopart.f I have attempted to find the original article, but was unable to locate it. It is, however, probably correct, as Chopart has many cases scattered throughout his excellent book.
The patient was a woman, thirty-seven years of age. Shortly after the beginning of pregnancy she suffered from retention of urine, and twelve days later several drops of puriform urine escaped. The abdomen increased in size day by day, and when she entered the hospital on September 7, 1781, she complained of abdominal tenderness. The skin was inflamed, and there was marked fluctuation around the umbilicus; the patient voided only in small quantities. She had high fever. Anthelme, surgeon-in-chief of the hospital, made an incision in the linea alba between the umbilicus and the muscle on the right, and a good deal of pus and a large quantity of fetid urine escaped. On the following day the symptoms were less acute. The clothes and the body were inundated with urine, and a large quantity of pus also escaped. On the next day the clothes were soaked with urine. The fever and other symptoms had disappeared, and the surgeon attempted to establish the return of the urine by the urethra. He was unable to introduce a sound into the bladder on account of some obstruction. Later on he was able to pass an elastic catheter into the bladder. The amount of urine escaping from the umbilicus diminished, and the pus in the urine gradually decreased. The pregnancy continued, and the patient left the hospital perfectly well. Normal labor took place in February, 1782.
Simon J says that at the meeting of the Medical Society in Florence, July 13, 1828, Betti reported a case seen by Falaschi, in which, as a result of a complete occlusion of the urethra at its vesical orifice, there was an escape of urine from the umbilicus in a patient very advanced in years. This phenomenon was observed for several months before death.
The various causes of blockage of the urethra have been:
1. A congeni tally closed urethra.
2. A congenital phimosis.
3. A stricture following gonorrhea.
4. New-growths of the bladder.
5. A vesical calculus.
6. An enlarged prostate.

URINARY FISTULA AT THE UMBILICUS, WITH ABSENCE OF THE URETHRA. The only case of congenital absence of the urethra with the escape of urine from the umbilicus with which I am familiar is that reported by Petit in 1837.
~~Littre: Histoire de l'Academie Royale des Sciences de Paris, Amsterdam, 1701, 27.~~
t Chopart: Maladies des voies urinaires, Paris, 1792. X Simon: Obs. 17, p. 33.

ACQUIRED URINARY FISTULA AT THE UMBILICUS. 611
Urinary Fistula at the Umbilicus, With Absence of the Urethra.* — The child was born with a closed urethra. At the umbilical cicatrix was a tumor the size of a cherry, from which urine escaped. A bandage was applied. The bandage retained the urine very well, but she was often obliged to remove it in order to relieve herself. The bladder was sensitive and did not hold more than half a glass of urine. As soon as it reached this degree of dilatation the child suffered from pain in the abdomen, particularly in the region of the bladder and the kidneys.

CONGENITAL PHIMOSIS WITH A URINARY UMBILICAL FISTULA. Freer, in his article on Abnormalities of the Urachus, refers to an article appearing in the Medical Record of August 18, 1871. A boy, a year old, commenced to pass his urine through a vesico-umbilical fistula. A few drops only passed by the urethra. An examination revealed a congenital phimosis with an orifice so small that the vis a tergo required to force the urine through it had exerted itself in an upward direction and had opened up the urachus, rendering that structure patent throughout. After this fistula had persisted for some time the cause was discovered, • circumcision was performed, and the urachus closed spontaneously.
Freer says this case emphasizes the importance of examining carefully the urethra before proceeding to operate for the closure of the fistula.

UMBILICAL URINARY FISTULA FOLLOWING STRICTURE OF THE URETHRA.
This is a very rare condition, considering the enormous number of patients who suffer from urethral stricture. Jacoby reported a case in 1877, and Guisy two cases in 1903. One of Guisy's patients also had an enlarged prostate which was probably a contributory factor to the urethral obstruction.
Umbilical Fistula Following a Urethral Stricture. f — The patient was a boy, eighteen years of age, who had contracted gonorrhea a year before and had developed a stricture. Later there was a perineal fistula. After taking balsam of copaiba he improved somewhat, but three months later the urine stopped completely for twenty-four hours. He suffered great pain and the umbilicus opened. Pus escaped, and then large quantities of urine, the continuous flow confining him to bed. When Jacoby saw him he had tuberculosis and syphilis. All the urine came from the umbilical fistula and none from the urethra. The fistula in the perineum was dry.
The umbilicus was flat. There was a very narrow fistula. Once the fistula closed and a small amount of urine escaped from the urethra. At the end of thirty hours, when the patient bore down heavily, the fistula reopened, and fully a quart of urine came away. This was mixed with pus and blood. The boy soon died. No autopsy is recorded.
An Umbilical Urinary Fistula Developing in a Man with Urethral Stricture and Enlarged Prostate. — • Guisy'sJ
~~Petit, J. L.: Traite des mal. chirurg., Chap, xi, 3. Oeuvres completes, 8°. Limoges,~~
1837. (Quoted by Simon, obs. 8.)
t Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, 202.
J Guisy, B.: Deux cas de permeabilite congenitale de l'ouraque. Ann. d. mal. d. org. genito-urin., Paris, 1903, xxi, 986.

612 THE UMBILICUS AND ITS DISEASES.
patient was a man sixty years of age, who, for five years, had been passing urine from the umbilicus. His previous history showed that he had suffered many years before with gonorrhea, and later with severe attacks of renal colic, accompanied by the passage of gravel from the urethra. He also had a urethral stricture. He developed pain and swelling about the navel. A physician opened the swelling and evacuated urine and pus, and thereafter the urine continued to flow by this route, as well as through the urethra. External urethrotomy was performed, and two large stones were removed from behind the stricture. The prostate was large. The urine ceased completely to flow from the umbilicus and recovery took place.
Escape of Urine from the Umbilicus Following Stricture of the Urethra. — Guisy's* second patient was a man aged thirtytwo years, who, on account of stricture following gonorrhea, had had great difficulty in passing urine and for two years had suffered pain at the umbilicus. Later a swelling appeared, and one day, during complete retention, the tumor ruptured and urine and bloody mucus escaped. Thereafter for several months there was constant leakage from the navel. A small sound could be passed through the navel into the bladder. The urethral stricture was treated by internal urethrotomy and dilatation, and the escape of urine through the navel diminished materially.

UMBILICAL URINARY FISTULA ASSOCIATED WITH A GROWTH IN THE BLADDER.
The only case of this character with which I am familiar is the one reported by Cadell in 1878.
Marked Cystitis in a Young Girl Followed by Escape of Urine from the Umbilicus. f — The patient was a delicate girl eight years of age. From her earliest childhood she had difficulty in making water. Micturition was frequent, and only a small amount of urine was passed. When she was six months old the lower abdomen and genitals became black and blue. The child went to school at four, but was taken home on account of pain and frequent urination. After an attack of typhoid fever at six years of age the other symptoms became more marked. Eight months before admission blood was noted in the urine. After a few days of great pain and swelling and hardness of the abdomen, the urine was observed to come in a small stream from the umbilicus. Nothing abnormal was noted in the appearance of the umbilicus or of the genitals. In the center of the umbilical depression was a fistulous opening into which a probe could be easily introduced and passed toward the bladder. A No. 2 elastic catheter introduced through the urethra was blocked by tenacious, mucopurulent masses in the bladder. The urethra was normal. No urine escaped by the urethra for several days. Later the urethra was dilated under anesthesia, and the procedure was followed by incontinence of urine.
The child died a few months later. At autopsy the bladder was found contracted and showed great thickening of the mucous and submucous coats. Protruding into the cavity were rounded nodules the size of peas. At the upper end of the bladder was the unobliterated urachus. It admitted the point of the little finger, gradually became narrower, and at the umbilicus admitted a No. 5 or No. 6 catheter. The
~~Guisy, B.: Loc. eit.~~
t Cadell, F.: Notes on a Case of Umbilical Urinary Fistula. Edinburgh Med. Jour., 1878, xxiv, Part i, 221.

ACQUIRED URINARY FISTULA AT THE UMBILICUS. 613
mucous membrane of the urachus was thin and pale. Between the umbilicus and the bladder were evidences of an old peritonitis, and the omentum was adherent to the anterior abdominal wall along the course of the urachus. There were dense adhesions binding the uterus to the posterior surface of the bladder.
The right kidney was twice the natural size, cystic, and filled with putrid and ammoniacal pus. There was complete atrophy of the kidney substance. The left kidney was one and a half times the natural size. The calices were distended with putrid pus, but the kidney substance had been only partially destroyed. Both ureters were dilated. Cadell says the urachus must have been partly open at birth.

VESICAL CALCULI OBSTRUCTING THE URETHRA AND ASSOCIATED WITH ESCAPE OF URINE FROM THE UMBILICUS.
Cases of this nature have been reported by Littre (1701), Raussin (1752), d'Auxiron (1766), Eustache (1789), Civiale (1838), Simon (1843), and Lexer (1898). In seven cases in which the sex was mentioned, five were in males and two in females. The ages varied from two and a half to seventy years. The age at which the patient came under observation is, however, no index as to when the symptoms first developed. For example, d'Auxiron's patient came under observation when he was seventy years old, but from the history it will be seen that he had had vesical symptoms since childhood. Eustache's patient, a boy six years old, had vesical symptoms shortly after birth.
The symptoms were usually those referable to a vesical calculus, and after various periods of time urine commenced to escape from the umbilicus. In some cases the umbilical fistula was preceded by an inflammatory reaction in the umbilical region; in other cases this phenomenon was apparently lacking.
Some of the patients were relieved by lateral lithotomy, and in Simon's case the stone was successfully removed suprapubically. After removal of the stone the umbilical fistula usually closed.
With our present mode of treatment these patients would naturally be operated upon soon after symptoms develop. If there be little or no infection, the fistulous tract should be dissected out and excised, and the stone removed suprapubically at the same time. When the inflammatory reaction is marked, the stone may be removed and the tract dissected out after the inflammation has subsided.

CASES OF VESICAL CALCULUS WITH ESCAPE OF URINE AT THE UMBILICUS. Vesical Calculi Followed by Escape of Urine at the Umbilicus.* — The patient was a priest, seventy years of age, who had suffered with vesical stone since childhood. He had piercing pains in the lower abdomen at times, and suffered from retention of urine, which sometimes lasted for several days.
For four or five years stones had blocked the urethra, and the urine had at times escaped from the umbilicus. There was a small opening with reddish margins at the umbilicus, out of which the urine oozed. Sometimes it came as a stream and could be caught in a vessel. When the urine escaped by the ordinary channel, the umbilical opening would close.
~~d'Auxiron: Une observation sur un homme qui rend ses urines par le nombril. Jour, de~~
m£d., Paris, 1766, xxiv, 58.

614 THE UMBILICUS AND ITS DISEASES.
Escape of Urine from the Umbilicus Due to a Vesical Calculus.* — In a patient seventy years old the urine escaped from the umbilicus in jets, in spite of the fact that the bladder was not extremely full. Each time it was found that a stone was obstructing the neck of the bladder.
Escape of Urine from the Umbilicus, Due to the Presence of a Vesical Calculus. — Civiale f says that Fourquet, of Toulouse, narrated to him the history of a child, thirty-one months of age, who was relieved by lithotomy. The vesical stone was voluminous, weighing 5.5 "gros," and enveloped in a covering of mucus and calcareous material. After about two months, as a result of considerable effort, the child expelled urine. It developed a urinary fistula at the umbilicus, from which three quarts or less of urine escaped. This closed after the operation.
Umbilical Urinary Fistula Associated With Stone Situated in the Neck of the Bladder. — Civiale also reports a case related by Covillard. The patient, a girl fifteen years of age, passed her urine from the umbilicus, and a stone was detected in the neck of the bladder. A lateral lithotomy effected an entire cure.
Urachal Fistula at the Umbilicus Associated With a Stone in the Bladder. — Lexer J reported a case that came under Goldschmidt's care. Goldschmidt operated on a ten-year-old boy on account of the gradual appearance of a fistula without signs of inflammation. This case was looked upon as one of urachal fistula of the abdominal wall, although no microscopic examination could be made. The boy had a large stone in the bladder. The fistula had produced an abscess-like dilatation below the umbilicus, and had been previously opened. At another time, when the cystitis had disappeared, the umbilical opening closed.
[This case is not particularly clear. — T. S. C]
Blockage of the Neck of the Bladder by a Stone; Partially Patent Urachus. — ■ Littre § demonstrated before the Paris Academy the body of a young man of eighteen. The neck of the bladder was occupied by a stone, and the urachus at the neck of the bladder was open for five fingerbreadths. He says that when the urine finds great difficulty in passing along its ordinary route, it commences to travel through its ancient channel.
A Renal Calculus Associated with Escape of Urine b y the Umbilicus. — Raussin|| reported before the Academy the case of a man, aged thirty-two years, who had had a renal calculus. In making an effort to urinate, while an attendant held the vessel, expecting to see a small stone fall into the vessel, he was greatly surprised to see urine passing from the umbilicus and from the penis at the same time. The umbilical stream was well formed, and made an arch over the shoulder of the servant, who at the time was kneeling. The umbilicus of the patient was represented as a tumor the size of a medium-sized walnut, with an opening in it which discharged a little blood. The patient continued to urinate by the
~~Civiale, Jean: Traitc de l'affection calculeuse, Paris, 1838, 257.~~
( Jiviale, Jean

Op. cit.
% Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. § Littre: Sur un foetus extraordinaire. Histoire de l'Academie Royale des Sciences de Paris, Amsterdam, 1701, 27.
1 1 Raussin : L'urine rendue par le nombril. Mem. de l'Acad. de Chir., Paris, 1752, ih, 10.

ACQUIRED URINARY FISTULA OF THE UMBILICUS. 615
umbilicus more than by the urethra, and claimed to be able to urinate by one or the other, as he desired. After a time most of the urine passed by the urethra.
Escape of Urine by the Umbilicus Due to Blockage of the Urethra by a Vesical Calculus.* — Dr. Eustache, surgeonin-chief of the Hotel-Dieu of Beziers, reported before the Academy of Surgery, in 1789, the case of a new-born boy who developed severe abdominal pain a few days after his birth. He was thought to have colic, but the usual remedies were given without success. At the thirteenth month he was weaned. The manner in which he urinated led to the supposition that he had a stone. When he was three years of age he drank to excess, and one day he consumed a pint of wine and became unconscious. The difficulty in urination increased. Sometimes he would have incontinence of urine, sometimes a dozen hours would pass without there being the escape of a drop. When five years of age he had complete retention of urine, and his abdomen was tender and painful, especially in the hypogastric region. His pulse was small and rapid, and the respiration was embarrassed. He had continual nausea. Pistre saw him on the third day, and at that time he had around the umbilicus a tumor which was inflamed, tender, and painful. Poultices were applied, and on the fourth day the child had not passed a drop of urine and was unconscious. On the fifth day there formed in the center of the umbilical tumor an opening about half an inch in diameter, and from this urine with pus escaped. Little by little the symptoms disappeared. The stomach retained nourishment, and he returned to the condition that he was in before the retention. The umbilical opening remained as a fistula and was the only passage by which the urine escaped. On the twenty-fourth of April, 1787, Eustache saw this patient, who was then six and a half years old. He had a slight fever and marasmus. Eustache confirmed the opinion of Pistre of the existence of a stone in the neck of the bladder, because a sound was arrested at this place and came in contact with a hard body. On the seventh of May of the same year, in the presence of several surgeons, Eustache extracted the stone through an incision in the perineum. It was in the shape of a large horn, and the lower extremity was engaged in the urethra. It was a little less than three inches long and 13^ inches in diameter. It was slightly concave toward the pubes, convex toward the rectum. After the extraction of the stone the urine commenced to escape through the wound, and in a short time the fistulous opening, which had been present for a year, closed. The urine contained much mucus. On the thirty-second day after the operation the urine commenced to pass by the urethra, and ten days later it passed entirely through this channel. The child made a good recovery.
Escape of Urine From the Umbilicus Due to Blockage of the Urethra by a Vesical Calculus. — Simon f reports the case of Marguerite P., aged twelve years, who had urinated by the umbilicus for four years. During this time not a drop of urine had escaped by the urethra. She had an enlargement of the abdomen, due to the escape of urine into the cellular tissue of the skin and of the muscle. She was brought to the hospital in May, 1786. With a sound an obstruction was found in the canal, which was preventing the flow of urine. The opening in the umbilical region offered a channel which communicated with the bladder. By this means it was possible to detect a stone fixed in the inner orifice of the urethra. The surgeon decided to pass a sound into the bladder by way of the urachus. The child was laid upon the table, the head and the buttocks being a little
~~Simon: These de Paris, 1843 (obs. 19), 34. f Simon: Op. cit. (obs. 25), 44.~~

616 THE UMBILICUS AND ITS DISEASES.
elevated. After the sound had been introduced into the bladder by way of the urachus an incision was made in the skin for about the length of three fingerbreadths in the linea alba, and ending at the pubes. The sound acted as a guide. The bladder was opened. The stone was the size of a pigeon's egg. After the extraction of the stone the child was promptly put to bed, and a sound was introduced through the urethra. At the end of four months the urine escaped regularly by the urethra.

UMBILICAL URINARY FISTULA ASSOCIATED WITH AN ENLARGED PROSTATE.
Levie, Lexer, and Monod have recorded cases in which a urinary fistula developed at the umbilicus in patients suffering from an enlarged prostate.
In this connection it may be mentioned that, according to Kirmisson, Horion observed an umbilical fistula that had developed after retention caused by a prostatic abscess.
A P a t e n t U r a c h u s A s s o c i a t e d W i t h an Enlarged Prostate.* — The patient was a man seventy-nine years of age. After several years of dysuria due to an enlarged prostate, the urine commenced to escape from the umbilicus. At autopsy the urachus. was found open. The opening into the bladder was tubular. The opening was from 1 to 1.5 mm. broad.
Markedly Enlarged Prostate, Followed by Cystitis and Escape of Urine From the Umbilicus. — Lexer f reports the case of a man, aged sixty-seven, who came to the clinic for three years on account of a prostatic hypertrophy and a resulting cystitis. He came whenever retention of urine developed. The urine was removed with a soft catheter, and the bladder washed out each time. The patient, on coming to the hospital later, said that, after there had been a stoppage of urine for twenty-four hours, it had commenced to come away by the umbilicus. He had noticed no unusual pain, and there was no inflammation in the region of the umbilicus. The entire flow of purulent, slimy urine escaped from the umbilicus.
On examination the patient was found to have a markedly enlarged prostate. A sound could be carried from the umbilicus for 6 cm. toward the bladder. From the umbilicus to the symphysis in the middle line a cord-like mass could be felt. [In such a case it would now be very easy to use bismuth paste and get a clear picture of the character of the fistulous tract by means of the x-ray. — T. S. C]
Lexer said that the almost complete lack of symptoms in the development of the fistula was a strong indication against perforation of the bladder with infiltration of the urine. He says that, in view of the slow development and the fact that the position of the fistulous tract was exactly in the mid-line, the whole picture tends to prove that the case was one of urachal fistula.
[With the present brilliant results obtained by prostatectomy, as carried out by Young and others in this country, the first thing would be to remove the prostate; this would materially improve matters, and later, if necessary, the fistulous tract could be closed.— T. S. C]
With a sound in the tract Lexer divided it. It was surrounded on all sides by very firm connective tissue, and about 5 cm. above the symphysis he found a cavity
~~Levie, L. : Een geval van profluvium urinae per umbilicum ab uracho patente bij een~~
volwassen persoon. Nederlandsch. Tijdschrift voor Geneeskunde, 1878, xiv, 501. t Lexer, E.: Loc. cit.

ACQUIRED URINARY FISTULA AT THE UMBILICUS. 617
the size of a walnut lined with slimy granulations and filled with purulent urine. This lay behind the abdominal wall and reached to the symphysis. The sac communicated with the bladder by a fistulous opening, the size of a lead-pencil. The entire wound was packed with iodoform gauze and a retention catheter left in.
The patient died fourteen days later with signs of uremia and fever. At autopsy a marked pyonephrosis was found on both sides. The small, thick-walled, ulcerated bladder ended in a small funnel just in the mid-line. Here it communicated with the opening in the abscess-sac. On the inner side of the abdominal wall was the median vesical ligament, appearing as a prominent cord 2 cm. broad.
From the results of the operation and from the autopsy specimen, it is clear that the bladder and umbilical fistula lay in the mid-line, and in the very markedly thickened median vesical ligament. The opening in the bladder was situated exactly in the middle of the vertex and in front of the peritoneum. In the fistulous tract it was impossible to make out any epithelium.
Lexer comes to the conclusion that these fistulous tracts should be dealt with early, before there is much inflammation; that is, in childhood.
Umbilical Urinary Fistula Associated With Hypertrophy of the Prostate.* — This case is particularly interesting. In a man, sixty-two years of age, the umbilical fistula developed after a prostatic hypertrophy. On looking into the history it was found that the patient had urinated from the umbilicus from the time of birth until he was three weeks old. The fistula had then closed spontaneously after the application of appropriate bandages.
Enlargement of the prostate is relatively common, and notwithstanding the tension under which the bladder labors in some of these cases, the escape of urine from the umbilicus is exceptional. It really seems as if the umbilical fistula only develops in those cases in which the urachus has remained partially patent, or where its lumen has persisted almost to the umbilicus.
- Bardeleben and Chapin have also reported cases in which an enlarged prostate probably existed. Bardeleben's patient was ninety-two, Chapin's was sixty-six, years old.
A Urinary Fistula at the Umbilicus Developing in a Man Ninety-two Years of Age. — ■ Bardelebenf says that, in the Memoires de l'Academie des Sciences for 1769, there is a report of a man, ninetytwo years old, who had severe pain in the neck of the bladder for several days. After the pain had ceased, he noticed that he voided less urine than usual and that his umbilicus was wet. A clear fluid (urine) was found escaping from the umbilicus. In fourteen days the urine by the urethra ceased. He died in six months. The fistula persisted until his death.
Escape of Urine from the Umbilicus in a Man Sixtysix Years of Age. — Chapin's f patient was a man, sixty-six years of age, who was seen in June with retention of urine. He suffered a great deal of pain and passed no urine for forty hours. The urine then began to dribble, and finally the bladder was emptied with a catheter. He suffered agony beyond expression during
~~Jaboulay: Reported by Monod, Obs. 53.~~
f Bardeleben: Lehrbuch der Chirurgie und Operationslehre, 1882, iv, 223. t Chapin, Edward: A Case of Open or Patent Urachus. North Amer. Jour, of Homoeopathy, New York, 1897, third series, xii, 286.

618 THE UMBILICUS AND ITS DISEASES.
the retention. The catheter was used for several days, after which he developed a great deal of soreness over the upper part of the bladder. Palpation over this region was painful. His pulse was slightly accelerated, but he had no fever. He voided small quantities of strongly ammoniacal urine containing mucus. Later excoriations were noted around the umbilicus, and some pus escaped from this opening. The discharge became more watery and had the odor of urine. The amount of urine escaping gradually increased, and by November 5th fully three-fourths of the urine was coming from the umbilicus. A small stream came from the urethra, a large one from the umbilicus.

APPARENT ESCAPE OF URINE FROM THE UMBILICUS, THE BREASTS, AND OTHER
PARTS OF THE BODY.
The accompanying remarkable case, recorded by Lynker in 1836, is difficult to interpret. I have found no similar case in the literature.
Lynker* reports the case of a woman, aged twenty-four, who in 1831 had a bad fall and became sick. In 1833 she had paralysis of the lower extremities. Later she had dysuria and passed hardly any urine. Her breasts swelled up, and she passed what looked like urine from them, then from the umbilicus, and later from the legs, the rest of the body skin meanwhile being dry. She had marked pain and swelling in the lower abdomen.
Up to the time of writing no clue as to the cause had been obtained. The patient was still alive.
~~Lvnker: Retention d'urine suiviede 1' excretion de ce liquide par des voies inaccoutumees.~~
Gaz. mid. de Paris, 1836, vii, 602.

LITERATURE CONSULTED ON ACQUIRED URINARY FISTULA AT THE UMBILICUS. d'Auxiron: Une observation sur un homme qui rend ses urines par le nombril. Jour, de med.,
Paris, 1766, xxiv, 58. Bardeleben: Lehrbuch der Chirurgie und Operationslehre, 1882, iv, 223. Binnie, J. F.: Development of the Urachus. Jour. Amer. Med. Assoc, 1906, ii, 109. Cadell, F.: Notes on a Case of Umbilical Urinary Fistula. Edinburgh Med. Jour., 1878, xxiv,
Part i. 221. Chapin, E.: A Case of Open or Patent Urachus. North Amer. Jour, of Homoeopathy, New York,
1897. third series, xii, 286. Civiale, J.: Traite de l'affection calculeuse, Paris, 1838, 261. Florentin, P.: Fongus de l'ombilic chez le nouveau-ne et chez l'enfant. These de Nancy, 1908-09,
No. 22. Freer, J. A.: Abnormalities of the Urachus. Annals of Surg., 1887, v, 107. Guisy, B.: Deux cas de permeabilite congenitale de l'ouraque. Ann. d. mal. d. org. genito-urin.,
1903, xxi, 986. Jacoby, M.: Zur Casuistik der Nabelfisteln. Berlin, klin. Wochenschr., 1877, 202. Kirrnisson: Maladies congenitales de l'ombilic. Traite des mal. chirurg. d'origine cong6nitale,
Paris, 1898, 208.
' 1 ue-Lasouree : D'un cas particulier ou les urines sortaient par l'ombilic. Jour, de m6d.,
Paris, 1811, xxi, 124. Levie, L. : Een geval van profluvium urinaj per umbilicum abs uracho patente bij een volwassen
persoon. Nederlandsch. Tijdschrift voor Geneeskunde, 1878, xiv, 501. Lexer, E.: Ueber die Behandlung der Urachusfistel. Arch. f. klin. Chir., 1898, lvii, 73. Littre: Sur un fcetus extraordinaire. Histoire de l'Academie Royale des Sciences de Paris,
Amsterdam, 1701, 27.

ACQUIRED URINARY FISTULA AT THE UMBILICUS. 619
Lynker: Retention d 'urine suivie de l'excretion de ce liquide par des voies inaccoutumees. Gaz.
med. de Paris, 1836, vii, 602. Monod, J.: Desfistules urinaires ombilicalesdues a la persistance de l'ouraque. These de Paris,
1899, No. 69. Petit, J. L.: Traite des malad. chirurg., Chap, xi, 3. Oeuvres completes, 8°. Limoges, 1S37. Raussin: L'urine rendue par le nombril. Mem. de l'Acad. de Chir., Paris, 1752, iii, 10. Simon, C: Quels sont les phenomenes et le traitement des fistules urinaires ombilicales. These
de Paris, 1843, No. 80. Starcke: Fall von Urachusfistel. Deutsche militararztliche Zeitschr., 1883, xii, 211. Trogneux, A.: Contribution a l'etude des fistules ombilico-vesicales. These de Paris, 1897, No. 129.

CHAPTER XXXVI.
URACHAL CONCRETIONS AND URINARY CALCULI ASSOCIATED WITH URACHAL REMAINS.
Historic sketch.
Urachal stones or concretions.
Urinary calculi in the urachus.
Removal of vesical stones through the umbilical opening.
Other calculi in the umbilical region.
Phillips, in an article in Todd's Cyclopaedia of Anatomy and Physiology (1835), said that in January, 1787, Boyer exhibited a bladder taken from a man thirty-six years of age. The urachus formed a canal 1^2 inches long, and contained 12 urinary calculi each the size of a millet-seed. It was demonstrated that this canal was not a vesical sac or a prolongation of the vesical mucous membrane.
In 1838 Civiale, in his treatise on calculous affections, called attention to the fact that the anatomist Colombus had observed calculi at the umbilicus. Civiale refers to the case of a woman coming under Hagendorn's care, who had a very painful abdominal abscess which contained two calculi. He also refers to Vallisnieri, who spoke of stones escaping from the umbilicus. In Helwig's case, cited by the same author, a woman seventy years old had an umbilical abscess; it broke, and several stones escaped, one of which weighed 15 grains. In another case a man discharged from the umbilicus a calculus which weighed about an ounce and was as large as a pigeon's egg. Civiale also referred to cases observed by Tolet, Rhodius, and Roesler. The stones varied from the size of the kernel of an olive to that of a hazelnut. They escaped from the umbilicus.
Simon, in 1843, mentioned the fact that calcareous concretions had been found along the course of the urachus and had also escaped through the umbilical ring. He said that Colombus, Donatus, Harder, Bartholin, and Cruveilhier had reported such cases. '
Simon said that Rhodius and Helwig had reported cases similar in character. In the case of Helwig's patient, a man, the stone was the size of a pigeon's egg.
Concretions or calculi escaping from the umbilicus may originate from several sources. They may be formed in the bladder or in the urachus, which communicates with the bladder, and where, consequently, urinary salts can become concentrated, or, again, in a urachus, that is completely isolated from the bladder. Finally we have umbilical concretions. The escape of gall-stones from the umbilicus has been considered elsewhere.
Calculi developing in a urachus communicating with the bladder are identical in their composition with vesical stones. Those developing in the urachus, when no connection exists between it and the bladder, are very small; umbilical concretions are cheesy in character. These last have been considered in detail in Chapter XV (p. 247).
The majority of the cases mentioned in the historic sketch just given are not
620

CALCULI ASSOCIATED WITH URACHAL REMAINS. 621
sufficiently clear to enable one to determine with any degree of accuracy to which group they belong.
URACHAL STONES OR CONCRETIONS.
The careful and painstaking investigations of Luschka, published in 1862, give us a very comprehensive knowledge of the urachus. He says the urachal contents are not all alike. The fluid is usually pale yellow, thin, and translucent. It may, however, be cloudy, and brown or reddish in color. It contains a large number of cells, numerous fat-globules, and not infrequently corpora amylacea. In the dilatations and in the isolated cysts the contents are frequently sticky and of a dirty brown color, and scattered throughout the field are bodies which have a marked resemblance to prostatic concretions.
Urachal concretions were also described by Hoffmann in 1870.
Suchannek, in 1879, when describing the contents of a patent portion of the urachus, discussed the granular bodies. These, he said, judging from their reaction to acetic acid, are due to a degeneration of the epithelium, which is probably colloid or amyloid in character.
Wutz briefly details his findings in the cyst contents of the many cases he examined.
In Case 11 he noted that, a short distance from the bladder, the urachus contained an oval body 0.17 x 0.1 mm. It was brownish in color and homogeneous in consistence. In the further course of the tube were several diverticula and nippedoff cysts of various shapes. They contained firm brownish contents.
In Case 15 Wutz says that the cysts were filled with lumps of brownish and yellow material.
In Case 17 the cyst contents were yellowish white and friable.
In Case 18 Wutz found a spindle-shaped urachal cyst, 2x1 mm. Its contents were brownish yellow in color.
Wutz, in summing up his observations on cyst-contents, said that they consisted of fat-crystals, fat-droplets, free fat, large flat epithelial cells, brownish-yellow amorphous masses, isolated cholesterin crystals, and small, round, very glistening bodies. In one of the cysts in Case 22 he found a small, firm, stony hard, yellowish-brown, glistening body. Under the microscope this was irregular, nodular,\ and partly transparent. It was 0.37 x 0.36 mm. in diameter. On the addition of hydrochloric acid free carbonic acid escaped.
Ledderhose referred briefly to urachal concretions in 1890.
In Boyer's case, which we have already considered and In which 12 millet-seedsized stones were found in the urachus, these bodies were urinary stones.
Rokitansky (1861) referred to a case in which 21 calculi the size of linseeds were found in a urachal dilatation 0.6 mm. above the top of the bladder.
Veiel, one of Luschka's pupils, in his dissertation on the urachus published in 1862, described his findings in the body of a man forty-five years old. "Passing downward in the mid-line from the umbilicus was a delicate cord 1 mm. broad. Three centimeters above the bladder it commenced to get thicker, and at the bladder was 1.2 cm. broad. The urachus could be divided into four sections. The lowest section, situated nearest the bladder, was 14 mm. long and patent. The next was 7 mm. long, solid, and thread-like. The third was 8 mm. long and was also patent. The fourth section— nearest the umbilicus— was solid. After the urachus had been

622 THE UMBILICUS AND ITS DISEASES.
treated with acetic acid, three dilatations of the canal could be seen. They contained yellowish concretions.
Arrou, in 1910, in an article entitled A Suppurating Cyst of the Urachus, reported a case in which an abscess contained a stone or concretion the size of an olive; it was like a piece of incompletely dried mortar. [I should be inclined to look upon it as a simple umbilical concretion accompanied by inflammation, were it not for the fact that the lower end of the sac bore a definite relation to the urachus. — T. S. C]
Suppurating Cyst of the Urachus. — Arrou* reports the case of a patient operated upon by Tricot. A soldier with absolutely no history of bladder trouble complained of vague pain in the umbilical region. The pain became acute, and the patient when marching had to bend forward. There was no nausea and no intestinal disturbance. Urination was normal; there was no fever.
Examination revealed a painful plaque, as large as the palm of the hand, a little below the umbilicus. There was no edema or redness. Gradually a little swelling was noted over the painful area; this was accompanied by some fever.
Operation. — An exploratory incision was made under the supposition that there was an abscess in the abdominal wall, but when the patient was in the operatingroom, there was an escape of a small amount of pus from the lower margin of the umbilicus. A probe introduced into the small orifice passed downward and backward into a cavity, measuring 6 cm. in its vertical direction. The patient was at once anesthetized and the cavity incised. It proved to be the size of a mandarin orange. It contained a calculus the size of an olive, that was like a piece of incompletely dried mortar. The cyst lining resembled an inflamed mucosa. Unfortunately, both sac and calculus were lost.
The upper end of the sac ended at the bottom of the umbilicus. The lower extremity terminated in a closed cul-de-sac. Attached to the lower portion of the sac was a large cord, the size of the little finger, which became smaller and terminated in the fundus of the bladder. Arrou was sure that it was the urachus. The peritoneum was opened above and laterally. The intestines were protected and the urachus was cut across with the cautery at a point several millimeters above the bladder. The sac was completely removed and the wound closed. The patient made a good recovery.
From the data at hand it is evident that urachal concretions or stones are very rare. They are usually no larger than linseed grains or millet-seeds. They are usually yellowish brown or brown in color, and may resemble corpora amylacea. They are too small to be a surgical factor, and are of interest only to the pathologist.

URINARY CALCULI IN THE URACHUS. In 1877 Vosburgh reported his observations on a man aged fifty, who had been complaining of a soreness and constant pain at the navel. Examination showed redness, tenderness, and a hard swelling around the umbilicus. The tumor was incised, and at the depth of half an inch a stone, the size of a hickory-nut, was felt and at once removed. The stone was phosphatic in character and had a strong urinary odor. The wound healed. The patient stated that, about twenty years before, a stone had been removed in a similar manner from this location.
~~Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832.~~

CALCULI ASSOCIATED WITH URACHAL REMAINS. 623
Monod, in 1899, referred to the stagnation of urine in the interior of the urachus as giving rise to calculi. He said that Colombus, Marcellus, Donatus, Harder, and Bartholin had cited examples of this kind. He added that the calculi may be eliminated through the umbilicus, as was noted by Hagendorn, Rhodius, and Hehvig.
The same author mentions a case recorded by Peyer in 1721, in which a calculus escaped from the umbilicus after retention of urine. In the chapter on Urachal Infections I have referred to a case reported by Weiser (p. 603). The patient, a woman seventy-five years of age, had had a purulent discharge from the umbilicus for fifteen years. When Weiser saw her she had a tumor the size of a cocoanut situated in the mid-line, between the umbilicus and symphysis. When this was opened, five ounces of very fetid pus escaped, and also a calculus weighing 70 grains. The wound healed in three months. Wishing to find out the character of this stone, I wrote Dr. Weiser, and from his reply it appears probable that it closely resembled a vesical calculus, but, as noted from the history, there was no opening into the bladder and no urine escaped from the incision during the patient's convalescence.
Probably one of the most interesting cases is the one recorded by Dykes. It might be claimed that the extravesical portion of the stone developed in a diverticulum of the bladder, but the location of the opening in the top of the bladder and in the median line leaves little doubt that the cavity was a dilated portion of the urachus, especially as the probe in the cavity could be carried up to within two inches of the umbilicus.
Patent Urachus and Encysted Urinary Calculi.* — "This case, which both in its clinical and pathologic bearings I believe to be of some interest, came under observation on January 27, 1908, at Rae Bareli Oudh:
"The patient was a Hindu male, aged about thirty years, apparently healthy apart from his urinary complaint, which dated back some five years or more. Owing to pressure of work I had not seen him until he was on the operating table, prepared for litholapaxy. The urine, I was informed, was acid and free from albumin. Several small concretions lay free on the base of the bladder, but on commencing to crush the first, the beak of the lithotrite impinged upon what appeared to be a much larger calculus, occupying a position at the apex of the half -distended bladder. After the first stone had been crushed the projecting portion of this larger calculus was easily seized between the blades of the lithotrite, but was found to be fixed to the bladder- wall.
"To crush this calculus in situ appeared dangerous, if not impossible, so lateral lithotomy was performed and the forefinger passed into the bladder. The calculus was now found j ust within reach of the finger. With the forefinger on the tip of the calculus and the other hand on the abdominal wall, it was estimated to be of considerable size, and its upper portion seemed very close under the examining hand beneath the abdominal wall in the middle line. It was evidently an 'hour-glass' stone, the deeper half being considerably larger than the projecting portion felt by the finger. The projecting portion being steadied in the grasp of the lithotomy forceps, the perforated end of a long probe was insinuated alongside the neck, and gradually manceuvered around the whole circumference, loosening the retaining tissue, until, by gentle traction and rotation of the forceps, an 'hour-glass' calculus was safely delivered. A second calculus immediately dropped from the same pocket into the bladder cavity. It, together with the three small concretions, the presence
~~Dykes, Campbell: The Lancet, 1910, i, 566.~~

624 THE UMBILICUS AND ITS DISEASES.
of which, on the bladder floor, had already been detected, was now removed, and the debris of the small stone, first crushed, washed out. In case other concretions might still be lying in the pocket its recesses were explored with a probe. Nothing further was found, but the probe passed up in the middle line, easily palpable through the abdominal wall, to a point two inches below the umbilicus. At the upper end the pocket seemed to be contracted to a mere sinus. Convalescence was rapid and uncomplicated.
"The ' hour-glass ' calculus weighed over l^ ounces. Its neck was of about the thickness of a cedar pencil, but somewhat flattened. The deeper lobe was larger than the projecting head, which was capped by a pea-sized, rough, dark-colored concretion, easily broken off, when drj", from the head proper. This terminal concretion resembled exactly, in color and approximately in size, the four small concretions which had been found free in the bladder, differing only in being rough and not polished or faceted by attrition. This resemblance strongly suggested that these four also owned the same source, from the head of the ' hour-glass ' calculus. Each weighed about 10 or 12 grains. The second encysted calculus showed a large oval facet corresponding to a like facet on the base of the 'hour-glass' calculus. Its longer axis had lain at right angles to that of the diverticulum in which it lay. It weighed just over half an ounce.
Neither in recorded cases nor in museum specimens have I come across any instance in which an encj^sted calculus had occupied the apex of the bladder. All the records I have found refer to basal or lateral sacculi, such as are commonly associated with enlarged prostate and chronic cystitis. This is so, for instance, in all the cases of encysted calculus included in the late Sir Henry Thompson's series of over 800 cases, the specimens of which are now in the museum of the Royal College of Surgeons of England. From the position and relations of the diverticulum this case appears to be an example of persistent patency of the lower end of the urachus, with calculus formation following, presumably on the accidental lodgment of a small concretion in it.
"While urachal cysts are much commoner in the female than in the male, a patent condition of the urachus leading to urinary umbilical fistula is much commoner in the male."
A Patent Urachus; Vesical Calculi; Sac-like Dilatations in the Urachus Containing Urinary Calculi; Removal of All the Calculi; Recovery. — During the meeting of the Southern Surgical and Gynecological Association held in Cincinnati on December 13, 1915, the President, Dr. Bacon Saunders, of Fort Worth, Texas, told me of the following interesting case that came under his care several years ago.
The patient was a boy about eleven years of age. He had had all the classic symptoms of stone in the bladder since infancy. Examination disclosed a fistulous opening at the umbilicus through which escaped quantities of foul-smelling urine. On a line from the umbilicus to the pubic region were five nodules ranging in size from a hazelnut to an almond.
A number of small calculi, resembling prostatic stones were removed from the bladder. An incision was made over each of the nodules in the mid-line below the umbilicus and a stone removed from each. These stones were of the same character as those found in the bladder. Urine escaped from the multiple openings for a while, but these openings eventually all closed, and the boy made a satisfactory recovery.

CALCULI ASSOCIATED WITH URACHAL REMAINS.

625

REMOVAL OF VESICAL STONES THROUGH THE UMBILICAL OPENING.
In the chapter on Congenital Umbilical Urinary Fistula (p. 507) I have quoted the well-known case of Paget and Bowman. The patient, John Conquest, an iron founder, forty years old, had had a urinary fistula at the umbilicus since birth. Paget detected a stone in the bladder. The umbilical opening being rather large, he introduced a finger, engaged the stone in the urachus, and brought it out through the umbilicus. This stone was irregularly ring-shaped, having developed around a curled-up hair (Fig. 221, p. 507). It was by getting the tip of his finger into the central hole in the stone that he was enabled to remove it by this route.
Nicaise refers to a case published by Faivre in the Journal de mecl. et chir., 1786. The patient, a small girl of twelve, had for four years passed her urine from the umbilicus. The urethra was obstructed by a calculus. Finally there was considerable engorgement of the surface of the abdomen, due to the urine escaping into the cellular tissue. Faivre entered the bladder through the umbilicus and removed the stone. A sound was introduced into the urethra, and the child made a complete recovery.
If urinary calculi develop in the urachus, they will naturally be found near the bladder, as indicated in Fig. 255.

Fig. 255. — A Patent Urachus Containing a Vesical Calculus. (Schematic.) The urachus is recognized as an open channel from the upper part of the bladder to the umbilicus. Just above the bladder it contains a spheric and rough vesical calculus. In the upper part of the umbilicus is a small umbilical hernia.

OTHER CALCULI IN THE UMBILICAL REGION.
On p. 337 we have discussed at length the escape of gall-stones at the umbilicus. The following cases, reported by Kostlin and by Bramann, while not strictly germane to the subject, are of considerable interest.
Communication Between the Gall-bladder and the Urinary Bladder, With Escape of Gall-stones Through the Urinary Tract. — Kostlin* cites the case of a patient whose history Faber had already reported in an inaugural dissertation. This woman first had
~~Kostlin, O.: Verbindung zwischen Gallenblase und Harnblase, mit Abgang von Gallensteinen durch die Harnwege. Deutsche Klinik, 1864, xvi, 116.~~
41

626 THE UMBILICUS AND ITS DISEASES.
trouble when thirty-five yea,vs of age. In the autumn of 1834 she had signs of peritonitis, with pains in the umbilical region. Later the pain was more marked above the symphysis. In October, 1835, she was again ill, this time with bronchopneumonia. On the fourth day there was pain over the symphysis, and the urine was blackish green (bile). The patient soon passed gall-stones, large and small, by the urethra. The gall-stones were examined chemically. The patient was kept under observation for years. She died, at sixty-three, with symptoms of bronchial catarrh and asthma.
Autopsy. — The liver was normal, but the entire organ was situated lower than usual. From the middle of the lower edge a rounded cord extended to the base of the bladder, passing in front of the intestine and pushing the transverse colon downward and to the left. The cord consisted of two portions — the lower and larger half was 1" 7.6"' (about one and three-fourth inches long) and was composed of the urachus. The upper, shorter half belonged to the lower portion of the gall-bladder. The entire length of this was 3" 1.5"' (about 3}4 inches long). The route which the bile and gall-stones traveled was from the gall-bladder through the urachus to the urinary bladder.
Kostlin mentions a similar case, reported by Pelletan.* In this case there was no autopsy.
Probably a Distended Gall-bladder Opening at the Umbilicus.! — The patient was a single woman, sixty-three years of age. She had had typhoid when thirteen. At the age of forty-five she had had sudden abdominal pain, accompanied by high fever, and there was much discomfort in the gall-bladder region. There was a tendency to vomit, and the abdomen was somewhat swollen. A tumor could be made out above and to the right of the umbilicus. It was the size of a fist and painful. The tumor persisted, grew slowly, and tended to pass more and more downward toward the symphysis.
Two years later a large quantity of foul pus escaped from the umbilicus. Pus continued to be discharged in varying amounts from the umbilicus for about sixteen years. The patient was otherwise in good condition.
On admission the abdomen was found to be slightly distended. The skin surrounding the umbilicus was covered with crusts, exfoliated epithelium, and small cysts. The umbilicus was drawn in, and in its center was a small discharging fistula. The escaping pus was foul-smelling. On palpation exactly in the mid-line a long, egg-shaped tumor was noted. At the umbilicus this was 5 cm. broad. It extended almost to the symphysis, and in its lower portion it was 7 to 8 cm. wide. The tumor lay distinctly behind the abdominal wall, and only in the neighborhood of the umbilicus was it intimately attached. In the lower part it was somewhat movable. On pressure it was found to be of dense consistence. A sound could be passed 12 cm. toward the symphysis and the cavity widened out. Calculi were detected at the bottom. Urination was always normal.
Operation. — The abdominal wall was incised for 8 cm. from the umbilicus downward. Four faceted calculi the size of pigeon's eggs were removed, and the tract was curetted out. Healing occurred after three months, but in the mean time it was necessary to curet the cavity several times. After several vain attempts Bramann found in some places many layers of squamous epithelium.
~~Pelletan: Jour, de chimie med., 2. ser., ii, Nos. 11 et 12.~~
t Bramann, F.: Arch. f. klin. Chir., 1887, xxxvi, 996.

CALCULI ASSOCIATED WITH URACHAL REMAINS. 627
Microscopic examination of the calculi yielded cholesterin and bile-pigment ; no urinary salts.
[The condition might well be explained by a gall-bladder extending into the pelvis and at the same time becoming adherent to the umbilicus. Everything points to this explanation, although Bramann considered the case to be one of open urachus. — T. S. C]

LITERATURE CONSULTED ON URACHAL CONCRETIONS AND URINARY CALCULI
ASSOCIATED WITH URACHAL REMAINS. Arrou: Kyste suppure de l'ouraque. Bull, et Mem. de la Soc. de chir., Paris, 1910, xxxvi, 832. Bramann, F.: Zwei Falle von offenem Urachus bei Erwachsenen. Arch. f. klin. Chir., 1887,
xxxvi, 996. Civiale, J.: Traite de l'affection calculeuse, Paris, 1838, 257.
Dykes, C: Patent Urachus and Encj r sted Urinary Calculi. The Lancet, 1910, i, 566. Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch, der
Heilkunde, 1870, xi, 373. Kostlin, O.: Verbindung zwischen Gallenblase und Harnblase, mit Abgang von Gahensteinen
durch die Harnwege. Deutsche Klinik, 1864, xvi, 116. Ledderhose, G.: Chir. Erkrankungen des Nabels. Deutsche Chirurgie, 1890, Lief. 45 b. Luschka, H.: Ueber den Bau des menschlichen Harnstranges. Arch. f. pathologische Anatoniie
u. Physiologie u. f. klin. Med., 1862, xxiii, 1. Monod, J.: Des fistules urinaires ombilicales dues a la persistance de l'ouraque. These de Paris,
1899, No. 62. Nicaise: Ombilic. Diet, encyclopedique des sciences medicales, Paris, 1881, 2. ser., xv, 140. Phillips, B.: Persistence of the Urachus. Todd's Cyclopaedia of Anatomy and Physiology,
1835, i, 393. Rokitansky, C: Pathologische Anatomie. 3. Aufl., Wien, 1861, hi, 372. Simon, C: Quels sont les phenomenes et le trait ement des fistules urinaires ombilicales. These
de Paris, 1843, No. 80. Suchannek, H.: Beitrage zur Kenntnis des Urachus. Inaug. Diss., Konigsberg, 1879. Veiel, E. : Die Metamorphose des Urachus. Diss., Tubingen, 1862. Vosburgh, H. D. : Patent Urachus with Calculus. Medical Record, New York, 1877, 606. Weiser, W. R.: Cysts of Urachus. Annals of Surg., 1906, xliv, 529. Worster, J.: Case of Vesico-abdominal Fistula of Fourteen Years' Standing. Medical Record.
1877, xii, 196. Wutz, J. B.: Ueber Urachus und Urachuscysten. Virchows Arch., 1883, xch, 387.

CHAPTER XXXVII. MALIGNANT CHANGES IN THE URACHUS.
Carcinoma of the urachus.
Historic sketch.
Symptoms.
Report of cases. Sarcoma in the urachal region. An extraperitoneal abdominal tumor.
A large multilocular carcinomatous cyst of the urachus; secondary growths in the pelvis (personal observation). A rare umbilical cyst.
CARCINOMA OF THE URACHUS.
I have been able to find three cases of carcinoma of the urachus recorded in the literature.
Sex. — All of the patients were men. Two of the patients had had congenital urinary fistula? at the umbilicus, and in each of these the discharge of urine had ceased after the use of escharotics. The third patient also evidently had a congenital fistula, as he gave a history of "moisture at the umbilicus" during childhood. This had ceased without treatment.
Age. — The patients were twenty-five, twenty-seven, and thirty-two respectively, indicating that, when carcinoma of the patent urachus develops, the malignant change occurs in early adult life.
Hoffmann and Fischer gave very careful and full histories of their cases. Hoffmann's patient, when twenty-seven years of age, noted a raised hardening between the umbilicus and symphysis. It was the size of a goose's egg, non-painful, and movable from side to side. It gradually extended toward the symphysis and right inguinal region.
Shortly after the tumor was noticed the patient experienced pain on urination. At times the urine was abundant, at times it came drop by drop. The man rapidly grew weaker and lost 25 pounds in four months. When Hoffmann saw him. the umbilicus presented a peculiar radiating appearance, while in the mid-line, just below the umbilicus, was a roundish, nodular tumor, 8 to 10 cm. long, adherent to the umbilicus and very painful. After the patient had urinated an area of tympany could be elicited between the tumor and the symphysis. On account of tenesmus, the patient urinated every hour. The urine contained pus and aggregations of epithelial cells.
The tumor became fluctuant, ruptured, and a large amount of purulent and bloody fluid escaped, but the growth did not diminish in size. From time to time onion-like balls escaped with the pus. These consisted of quantities of squamous epithelial cells that had become agglutinated. Precisely similar balls escaped in Fischer's case.
The urethra was normal.
628

MALIGNANT CHANGES IN THE URACHUS. 629
The umbilical opening closed temporarily, but soon reopened, and in the late stages of the disease the inguinal glands were swollen.
As noted in the autopsy report, the cavity between the umbilicus and bladder had walls 1 cm. thick. Its inner surface had an irregular, ulcerated, and eaten-out appearance (Fig. 256). The bladder-wall had been involved by continuity, and also contained secondary nodules. The growth was a squamous-cell carcinoma.
Fischer's patient, when thirty-one years old, first noted a small, hard tumor the size of a pigeon's egg below the umbilicus. Seven or eight months later he had pain on micturition, and noticed a sediment in the urine. The nodule was incised on the supposition that it was fluctuant, and slimy, necrotic tissue escaped. The tumor soon grew out of the incision, bled a great deal, and finally left an ulcerated area, the walls of which were raised and hard, while the floor consisted of hard nodules. From the ulcerated area onion-like balls of epithelial cells escaped.
The inguinal glands on both sides became swollen. At autopsy the bladder mucosa showed a catarrhal swelling, but no involvement by the malignant growth. The prostate was normal. The growth was a carcinoma, evidently of the squamouscell type, as indicated by the onion-like balls.
Death in these cases may occur from gradual weakening as a result of the disease, or from a perforation of the growth posteriorly into the abdominal cavity, causing a peritonitis. The occurrence of three cases of carcinoma of the urachus is another point in favor of the early removal of the patent urachus.
In the future cancer of the urachus, when met with, will undoubtedly be operated on early. The growth can be given a relatively wide berth, and the block dissection should include the inguinal glands on both sides.
Cases of Carcinoma of the Urachus Developing Years After the Closure of a
Congenital Patent Urachus.
Carcinoma Evidently D e v e 1 o p i n g F r o m Remains of the Urachus. — Fischer* saw this patient in consultation with Hanuschke in 1874. The man, thirty-two years of age, sought treatment on account of an ulcer of the umbilicus. During his childhood, when voiding, there was a moisture at the umbilicus. Later these symptoms disappeared and there was never any trouble with urination. Early in 1873 he casually noticed below the umbilicus a hard tumor the size of a pigeon's egg. This gave rise to no symptoms. It gradually grew, and seven or eight months later there were pain and a burning sensation on micturition and sediment in the urine. Toward the end of 1873 he consulted a physician. The difficulty in urination had increased, and the tumor had grown markedly. His general condition was not satisfactory. Hanuschke thought that the tumor was soft, and that he could make out fluctuation. Accordingly he made an incision, and purulent, slimy masses escaped — evidently pieces of necrotic tissue. The tumor mass grew out of the incision wound ; it very soon broke down, with a good deal of bleeding, and an ulcer resulted. When Fischer saw the patient, he was pale and weak, had difficulty in micturition, and suffered from strangury. The ulcer was situated 2 cm. below the umbilicus, and formed a deep crater, which was heart-shaped. Its walls were elevated, hard, and extended below the level of the skin about 4 cm. Its greatest breadth was 8 cm. Its greatest length, 7 cm. The floor was very irregular
~~Fischer: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, n. F. No. 89 (Chir. No. 24), Leipzig, 1894, 519.~~

630 THE UMBILICUS AND ITS DISEASES.
and covered with hard nodules. It reached a depth of 5 cm. below the skin surface. Surrounding the ulcer the tissue was hard. On pressure there escaped a thin, bloody, foul-smelling pus from the ulcer, and there were also portions of the tumor forced out as small balls suggesting onions. These were composed of quantities of flat epithelial cells.
The urine was acid, slightly cloudy, and had a purulent sediment. The inguinal glands on both sides were swollen.
Complete removal of the growth was impossible. The abdominal walls, however, were split in the mid-line as far as the symphysis, and beneath the muscle thick, pork-like tumor masses were found adherent. As much of the tumor as possible was removed, and the cautery was employed. The patient died fourteen days after the operation. Microscopic examination of the tumor mass showed it to be a carcinoma. At autopsy the inner surface of the bladder was found to show catarrhal swelling. It was intact. There was no abnormality in the prostate. The intestines were normal.
A Patent Urachus, Closure; Later Carcinoma of the Urachus.* — This case was also mentioned in the Deutsche Klinik, 1864, xvi, 116. The patient was a man, twenty-eight years of age, who had a urachal fistula at birth. This was healed with escharotics. Twenty-five years later a tumor developed between the umbilicus and the symphysis. This broke and discharged pus and later urine. The autopsy revealed a carcinoma of the mucosa of the urachus, which had perforated into the umbilicus and into the bladder.
A Patent Urachus Partly Closed by the Use of Escharotics; Later, Carcinoma of the Urachus. — Hoffmannf first reports the case of Hermann R., in which there was an enormous sac formation and accumulation of fluid outside of the abdomen. This Hoffmann attributed to a dilated urachus.
Hoffmann reports the case of Alexander Wanner, a postal employee, who was born in 1841 with an opening at the umbilicus through which urine escaped, while it also passed from the urethra. This condition lasted until his third year, when the opening closed after the use of escharotics. The patient had no further difficulty, and with the exception of several inflammations of the eye was perfectly well. About the middle of the year 1868 he noticed between the umbilicus and the symphysis, near the umbilicus, a raised hardening of the abdomen about the size of a goose's egg, which was not painful and could be pushed from side to side. This gradually grew and extended toward the symphysis, and spread toward the right inguinal region. Shortly after the appearance of the tumor the patient began to have pain on urination. The urine sometimes came in an abundant stream; at other times only in drops. As a result the patient had a continuous desire to urinate. The pains became severe and he grew weaker. He had lost weight — in the last four months, 25 pounds. On admission to the hospital, November 10, 1868, he weighed 99 pounds, was poorly nourished, anemic, and had a peculiar radiating formation of the umbilicus, in the folds of which no opening could be discovered. Immediately below the umbilicus was a tumor, 8 to 10 cm. long, situated in the middle line. It
~~Graf, Fritz: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.~~
t Hoffmann: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch. d. Heilkunde, 1870, xi, 373.

MALIGNANT CHANGES IN THE URACHUS. 631
was roundish, nodular, very painful, and adherent to the umbilicus, but on both sides it was free. After urination, between the tumor and the symphysis was an area of tympany. On account of the tenesmus the patient urinated every hour, and the urine contained pus and aggregations of epithelial cells. The patient drank quantities of soda-water and local applications were made. His pain diminished, but the tumor continued to grow. The umbilicus became prominent, fluctuation was detected, and on December 1st the swelling broke and a large quantity of thick, purulent, bloody fluid escaped. The tumor, however, did not diminish in size, although the pain became less and less. In the fluid numerous onion-like balls were found. These consisted of large quantities of squamous epithelial cells which had become agglutinated.
Examination of the urethra with a bougie yielded nothing abnormal. The prostate was not enlarged, the bladder-wall was thick and did not contract completely after the escape of urine. From September 4th urine and purulent fluid often escaped from the umbilicus, and the urine passed from the bladder from that time on was cloudy. The opening at the umbilicus gradually contracted, and for some time only purulent fluid escaped from it. The tumor became smaller, and toward the middle of January, 1869, the umbilicus closed completely.
Diarrhea developed and marked emaciation. At the end of January the opening at the umbilicus reappeared, and a purulent-like material escaped. The pain became more severe. The inguinal glands were swollen and the patient grew weaker. On January 31st he weighed 88 pounds. He died in the middle of May, 1869.
Only an incomplete autopsy could be obtained. The family physician who made it said there were appearances of peritonitis. The umbilicus had a peculiar, radiating, stellar appearance, and there was an opening 3 mm. in diameter. Through this there was a passage going downward and backward into a canal which gradually widened. The cavity had walls 1 cm. thick. It extended from the umbilicus to the top of the bladder. It was 10 cm. in length, and in its middle portion was 2.5 cm. broad. The entire inner surface presented an ulcerated, irregular, much eaten-out, reddish appearance (Fig. 256).
At its lower part this cavity communicated with the bladder by an opening 3.3 cm. broad, and the posterior wall of the bladder was invaded by this ulcerated growth over an area 4 cm. in diameter. The bladder-walls, where invaded, were 1.8 cm. thick, while the unchanged portions were 0.8 cm. thick. At the point where the cavity communicated with the bladder posteriorly was a perforation, the exact size of which could not be determined on account of the tearing of the specimen. The bladder mucosa, on the whole, looked normal, but at one point in the anterior wall was a round nodule, 1 cm. in diameter; in the posterior wall were several smaller ones.
Microscopic examination showed that the growth of the urachus was a squamouscell carcinoma, and that the secondary nodules were also carcinomatous.
Hoffmann says that this patient was born with a patent urachus. The opening at the umbilicus had closed after the use of escharotics in the third year. In the twenty-seventh year a carcinoma developed in the urachus and extended to the bladder. The perforation caused by the cancer led to a local peritonitis.
A Urachal Cyst and Cancer of the Bladder Occurring Independently. — ■ Rotter's case may well be considered here. The urachus

632

THE UMBILICUS AND ITS DISEASES.

J- 'ig. 256. — Carcinoma of the Patent Ubachus. (After C. E. E. Hoffmann.) A is a partially diagrammatic picture: ", The anterior abdominal wall; b, the opening of the urachus at the umbilibe urachus, which is occupied by a carcinoma; at d the growth has broken through into the abdominal cavity; < , the bladder. At points /, /, /, /, on the bladder mucosa are small secondary carcinomatous masses. B represents the appearance of the umbilicus with the opening of the urachal fistula in its center.

MALIGNANT CHANGES IN THE URACHUS. 633
was the seat of a cyst and the bladder showed a carcinoma. The one was absolutely independent of the other.
Rotter's* patient was a forty-three-year-old man, who, for nine months, had had bleeding from the bladder. Cystoscopic examination showed a tumor in the upper portion of the bladder. This did not grow rapidly. Above the symphysis, and reaching to the umbilicus, was another tumor, which on aspiration yielded a fluid containing cholesterin. This tumor was diagnosed as a urachal cyst. At operation the upper tumor was found lying between the peritoneum and the abdominal muscles. In its upper portion it was free, but over the lower half it was so intimately blended with the peritoneum that it was necessary to remove a portion of the peritoneum with the tumor. The urachal tumor pressed so into the bladder muscle that it was also necessary to open this viscus.
The cancer of the bladder was removed, and a defect 7 by 8 cm. in the bladder closed by layers. This patient was shown by Rotter at the Berlin Surgical Society. Microscopic examination demonstrated carcinoma of the bladder. This had perforated at the point where the cyst was found. The cyst contained many polymorphous epithelial cells. There was no doubt that it was a urachal cyst.
Possibly an Adenocarcinoma of the Urachus. — I am at a loss where to place this case of Koslowski's.f The situation of the tumor suggests a urachal growth. Furthermore, the variation in the size of the glands might very readily correspond to the cyst-like spaces we have noted where isolated segments of the urachus have persisted. The invasion of the rectus sheath and of the rectus muscle naturally points toward malignancy. We shall accordingly leave this case among those of carcinoma of the urachus. Whether it really belongs here or not is problematic.
The patient was a man, fifty-five years of age, who five weeks before had noticed in the mid-line, between the symphysis and the umbilicus, a small, painful tumor which grew to the size of a walnut. This man was markedly emaciated, looked to be seventy years of age, had frequent diarrhea, and was bent over from guarding the abdominal muscles. Between the umbilicus and symphysis, near the mid-line, was a tumor which suggested a patella. The overlying skin was free. The tumor was slightly movable and very painful. It felt very tense, and gradually merged into the surrounding tissue. Passing from the tumor toward the umbilicus was a cord the size of a goose-quill. Koslowski thought the tumor was a malignant epithelial growth developing from remains of the urachus.
Operation. — A median incision showed that the linea alba and sheath of the rectus had been penetrated by the tumor. An elliptic incision encircled the umbilicus and the tumor. Removed with the tumor were portions of the sheath of the recti and some of the rectus muscle, the transversalis fascia, and peritoneum. After the abdomen was opened, the tumor was drawn up and brought into view fibrous cords passing to the umbilicus. The upper cord was the size of a goose-quill, firm, and infiltrated. The lower cord was less firm and contained veins; these passed into the vesico-umbilical ligament. The peritoneum covering the posterior surface of the tumor showed evidence of scar and of ulceration. The patient made a good recovery. The tumor in form resembled a patella. The peritoneum was firmly
~~Rotter: Blasencarcinom combinirt mit Urachuscyste. Centralbl. f. Chir., 1897, xxiv, 604.~~
t Koslowski, B. S.: Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir.. 1903, lxix. 469.

634 THE UMBILICUS AND ITS DISEASES.
attached to it. The surrounding muscle was penetrated by the tumor. Microscopic examination showed that it was made up of glands of various sizes. They varied from the size of urinary tubules to those large enough to be noted with the naked eye. The diagnosis was fibro-adenoma submalignum. The glands resembled intestinal glands.
[It is difficult to establish the exact character of this tumor. — T. S. C]

SARCOMA IN THE URACHAL REGION.
Frank, in 1893, recorded a very interesting case of sarcoma probably developing in the sheath of the urachus in a young lad. Unfortunately, the subsequent history of the case is lacking, but the histologic picture of the growth, the invasion of the muscles of the abdominal wall, and the secondary nodules in the omentum leave no doubt as to its malignancy.
Alban Doran reports a case of sarcoma developing in the wall of a cyst of the urachus. This is so interesting that I shall also record it in detail.
Sarcoma Probably Developing in the Sheath of the Urachus. — Frank* gives a good resume of the literature and reports the case of a boy eleven years of age. For several weeks he had had loss of appetite and was losing weight. About fourteen days before the boy came under observation the father noticed a swelling in the umbilical region, and from a small opening at the umbilicus a little pus could be pressed. There was no urinary difficulty and no discomfort on defecation. The urine, however, had recently became cloudy and stringy. The child's mother had died of pulmonary disease, otherwise the family history was good.
On examination the boy was found to be strong and well nourished. In the umbilical region was a hard, circumscribed thickening, only slightly painful on pressure, reaching about a fingerbreadth above the umbilicus. Here it could be traced three fingerbreadths to the right and to the left of the linea alba. Below it extended almost to the symphysis. The skin over the tumor was only slightly movable. A sound introduced into the sinus passed from 4 to 6 cm. downward. With a sharp curette friable, sanguineopurulent masses were removed. These on examination were found to consist of pus-cells, granulation tissue, and debris.
Operation. — An elliptic incision was made, commencing 3 cm. above the umbilicus. The recti muscles at the umbilicus were found to be infiltrated by the growth. The incision was then carried through healthy muscle to the peritoneum. Loops of small bowel were adherent to the peritoneal surfaces of the tumor, and nodules were found scattered throughout the omentum. The tumor was gradually turned out ward and was removed without much difficulty. Its lower end was intimately adherent to the bladder, and the outer walls of this viscus were removed and the small opening in it was closed. The omentum was removed on account of the tumor nodules. The abdomen was closed with difficulty. The patient's recovery was slow.
The tumor, on section, was found to have invaded the recti in all directions. Its chief extension was along the course of the urachus as far as the bladder. The tumor itself, with the surrounding parts, was as large as a man's fist, and was nodular and uneven.
~~Frank, Theodor: Zur Casuistik der Urachustumoren. Inaug. Diss., Wurzburg, 1893.~~

MALIGNANT CHANGES IN THE URACHUS. 635
On microscopic examination the sarcomatous character of the tumor was evident. In the center of the tumor the intercellular substance was most marked, but toward the periphery it consisted almost entirely of spindle-cells with little connective tissue. The growth of the spindle-cells into the recti and into the bladder was especially evident. The entire picture indicated that the tumor had developed in the connective-tissue layers of the urachus and that it had then spread out in all directions.
The case is perfectly clear, but there is no after-history beyond two months, and no description of the omental nodules.
AUniqueSpecimenofCystic Sarcomaof the Urachus.* — Alban Doran says: "Mr. F. S. Eve has presented to the Museum of the Royal College of Surgeons of England a unique specimen of cystic sarcoma of the urachus, and has kindly supplied me with the following notes :
' ' A man, aged thirty-eight years, was admitted into the London Hospital with a swelling in the hypogastrium noticed for several weeks and associated with pain after micturition. A cystic tumor filled the lower part of the abdomen, especially to the right, where it extended toward the loin. It did not dip into the pelvis. On puncture, dark blood came away; a few days later a rigor occurred, with vomiting and a rise of temperature to 104° F. Mr. Eve then operated, exposing a large cystic tumor; the parietal peritoneum was reflected over its anterior and superior surfaces. Five pints of dark, bloody material were removed. The cyst adhered to the omentum, which bore engorged veins, and to an inch and a half of small intestine which was infiltrated where adherent. The adherent portion of the wall of the gut was excised, and the wound closed with sutures. The lower part of the cyst was intimately connected with the bladder, the serous coat of which organ was reflected onto its surface. This peritoneal covering was divided, and the cyst carefully dissected away from the bladder. During the process the bladder was opened, for the vesical wall at this point was so thin that the cavities of the cyst and the bladder were only separated by the vesical mucous membrane covered by a few muscular fibers. The opening was sutured, but not without great difficulty, owing to the thinness of the walls at this point. The sutures were further protected by gauze packing. A gauze drain was passed into the pelvis, and a catheter retained for a while in the bladder. Neither flatus nor feces could be made to pass after the operation, and the patient died on the fourth day. There was no general peritonitis, but the pelvic peritoneum had become inflamed at the point where the gauze had been applied.'
"Mr. Eve examined the specimen and found that it was a large allantoic cyst separated from the posterior superior surface of the bladder by nothing except a very much thinned mucous membrane. Their cavities, however, did not. communicate. The inner wall of the cyst was lined at certain points with very vascular polypoid masses, which proved to be, on microscopic examination, sarcomatous. The most unusual feature of this cyst was its malignancy, but its peritoneal relations were of greater importance in respect to the subject of this communication."

AN EXTRAPERITONEAL ABDOMINAL TUMOR. The following interesting case, the specimen from which was exhibited by Dr. Aveling, may be considered here, although from the description one could not say
~~Doran, Alban H. G.: The Lancet, 1909, i, 1304.~~

636 THE UMBILICUS AND ITS DISEASES.
that the growth was a sarcoma. It may serve, however, to form the nucleus around which similar cases may be collected.
Dr. Aveling* exhibited before the British Gynecological Society a subperitoneal tumor which had grown in the anterior abdominal wall and reached from two inches above the umbilicus to the pubes. It was removed after death, the patient having succumbed after an exploratory operation. Sir Spencer Wells, who saw the tumor, said he had seen only two similar cases, and he classified the tumor, according to Virchow, as a fibroma molluscum cysticum abdominale. The specimen was referred to Mr. Bland-Sutton and Dr. Aveling for further examination.
The tumor was ovoid in shape, and measured 10 inches in length, 7 inches in width, and weighed 4% pounds. It was surrounded by a distinct, thick, fibrous capsule. On section the tissue was of a dirty white color, and the cut surface looked like a sponge. The loculi were filled with gelatinous tissue, which readily broke down on scraping the cavities with the handle of a scalpel. Inside the growth six or seven hard nodules, of the size of walnuts, could be felt. These, when dissected out and divided, looked like small leiomyomata, such as occasionally exist in the uterus. They presented the same whorled arrangement of the fibers, and corresponded with them histologically. On microscopic examination of the tumor the outer portion was found to consist of non-striped muscle-fibers, some of large size. Internal to this the cells assumed more the shape and characters of those seen in spindle-cell sarcomata, while the gelatinous material contained in the loculi was the result of mucoid degeneration of the sarcomatous elements.
Sutton and Aveling then go on to say that the specimen was of great interest from an etiologic standpoint. "Man, in common with other mammals, possesses a persistent pedicle of the allantois, familiar under the name of the urachus. This structure is frequently found dilated into a cyst, usually of small size. An account of these allantois cysts, with reference to a few recorded cases, will be found in the Path. Soc. Trans., xxxvi, 523." They drew attention to the fact that Mr. Lawson Tait, in his work on Diseases of the Ovaries, had described certain growths which he regarded as probably originating in the urachus, and which attained such considerable dimensions as to require operative interference.
They thought that, in the present case, they had to deal with an allantois cyst, the walls of which had become sarcomatous, thus affording another illustration of the great tendency exhibited so often by aberrant and ill-developed structures to become the seat of morbid growths, such as sarcoma or carcinoma.
[After a somewhat careful study of the literature on the subject of umbilical tumors, the interpretation of Bland-Sutton and Aveling is not altogether clear. It would rather seem as if we are dealing with a myoma. The gross description speaks of non-striped muscle, and this the histologic picture substantiates. The gross and histologic appearance of the nodule coincides with the appearances presented by uterine myomata. The areas that were supposed to be sarcomatous and inclosed cavities presenl ing a m ucoid appearance might very readily have been due to hyaline degeneration. Without an opportunity of examining their specimen we should hesitate to express any definite opinion as to this case, further than that their interpretation does not seem to tally with the recorded cases of secondary growths attributed to the allantois. — T. S. C]
Doran* says that Aveling and Bland-Sutton had already reported a case of
~~Aveling: Brit. Gyn. Jour., 1886-87, ii, 56 and 187.~~
t Doran, Alban H. G. : The Lancet, 1909, i, 1304.

MALIGNANT CHANGES IN THE URACHUS.

637

multilocular myxosarcoma of the sheath of the urachus, but it did not involve the urachal canal, and was quite unconnected with the bladder. The specimen (No. 417 b) in the pathologic series of the Museum of the Royal College of Surgeons of England was supposed, when first examined, to have developed in the urachus, but Mr. J. H. Targett considered that it was a myxosarcoma which had originated in the connective tissue surrounding the bladder.
After I had made my comment on Aveling and Bland-Sutton's case, Alban Doran's note on the case came to my notice, clearly showing a lack of unanimity of opinion among those who had examined the specimen, not only as to the exact character of the tumor, but also as to its precise source of origin.

Multilocular urachus cvsi

Omentum, adherent" to tumor

Fig. 257. — A Multilocular and Malignant Cyst of the Urachus. Gyn.-Path. Nos. 10368 and 1048S. The cyst lay between the abdominal muscles and the peritoneum of the anterior abdominal wall. Below it was attached by a pedicle near the top of the bladder. Upward it extended for a considerable distance above the umbilicus. The omentum was densely adherent to its upper surface. The cyst -wall anteriorly was so thin that I cut it, thinking that it was peritoneum. The cyst is composed of one large and many smaller cavities. Projecting into the large cyst are many smaller cysts, and papillary and solid growths spring from the inner surface of the cyst. Some of the smaller cysts have smooth walls, as is well seen in the one near the pedicle of the tumor. Cross-sections of other small cysts show that they are partially filled with secondary growths. It will be noted that the uterus, tubes, and ovaries are absolutely independent of the cystic tumor. They are, however, partially covered over with secondary cancerous nodules. (For the histologic appearances in this case see Figs. 261, 262, 263.)

A LARGE MULTILOCULAR CARCINOMATOUS CYST OF THE URACHUS; SECONDARY
GROWTHS IN THE PELVIS.
I saw Mrs. W. W., aged thirty-seven, in consultation with Dr. E. S. Mann, of Dallastown, Pa., and had her admitted to the Johns Hopkins Hospital, October 6, 1906. This patient had never been pregnant. Her menses had commenced at fourteen and had always been regular until the previous year. Her last period had occurred sixteen months before admission. About two years before I saw her,

638

THE UMBILICUS AND ITS DISEASES.

she had noticed, on moving, a sharp, sticking pain in the left lower abdomen. For about a year and a half she had had some abdominal enlargement, and eight weeks before admission the abdomen had commenced to swell a great deal. The feet and legs had also been swollen. The patient gave a history of having lost 20 pounds in

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the past six months. She had had dysuria, and had had to void four or five times during the night.
On admission it was noted that she was a well-nourished woman, weighing 172 pounds. The abdomen was markedly distended. It rose rather abruptly from the symphysis to the umbilicus, and then gradually shaded off to the xiphoid. On

MALIGNANT CHANGES IN THE URACHUS.

639

percussion fluid was evident in all parts of the abdomen. About two months before she had noticed large and small lumps in various parts of the abdomen. Some of these were fully an inch in diameter, and they had sharp edges.

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Fig. 259. — Giant-cells in the Wall of an Adenocarcinoma of the Urachus. ( X 90 diam.) Gyn.-Path. Nos. 10368 and 104SS. At a is a slit-like space lined on both sides with a large giant-cell. The nuclei of the giant-cells are irregularly distributed and stain deeply. Extending from one end of the space to the other is a delicate strand. This, under a higher power, was found to contain two small nuclei. At b is an irregular oblong space with a large giant-cell in the center of its upper margin, and an irregular mass of protoplasm containing numerous nuclei bordering its lower margin; projecting into the cavity from either end are delicate filaments of stroma devoid of nuclei. At c is a series of parallel slits. The tissue at this point consists of hyaline material. Most of these slits have no lining whatsoever, but both the upper and lower slit have small giant-cells attached to their margins. At d is a slit-like space lined with giant-cells, e is a giant-cell that could be clearly focused at another level. It was irregularly triangular in shape, and contained a quantity of oval, uniformly staining nuclei arranged chiefly at one end of the cell. There were other giant-cells scattered throughout the field. The protoplasm of some of these was brownish in color, apparently owing to the absorption of old blood-pigment. The stroma of the cyst-wall in this region consisted of fibrous tissue. In the vicinity of these giant-cells and in the neighborhood of the slit-like spaces it showed a great deal of hyaline trans formation; many of the small round-cells that still persisted were swollen and contained a yellowish or brownish pigment — undoubtedly caused by old hemorrhage.

On pelvic examination the cervix was found to be perfectly normal; nothingfurther could be made out.
Operation (October 8, 1906). — On opening the abdomen I immediately came

640

THE UMBILICUS AND ITS DISEASES.

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MALIGNANT CHANGES IN THE URACHUS. G41
in contact with the contents of a cyst. This cyst was large, multilocular, and intimately adherent to the anterior and lateral abdominal walls (Fig. 257). At first I thought it was impossible to remove it, but on continuing the incision upward we entered the general peritoneal cavity. I then delivered the tumor from above downward. Its pedicle sprang from the top of the bladder. This pedicle was 1 cm. broad and 2 mm. thick. Raw areas were left, both on the anterior and lateral abdominal walls. The bleeding was checked by sliding over the peritoneum as far as possible, thus bringing the raw areas together and diminishing the size of the denuded space.
Both ovaries were normal in size, but were somewhat glued down to the pelvic floor. As the pedicle of the cyst sprang from the bladder, I thought it advisable to turn it in, fearing that there might be an opening between the bladder and the cyst. In the pelvis were metastatic deposits, some of them very minute, others irregular, somewhat translucent, and fully 1 cm. in diameter. The appendix was removed, and the abdomen closed. The patient was discharged November 5, 1906. In answer to an inquiry Dr. Mann wrote me that the patient died January 8, 1908.
Gyn.-Path. Nos. 10368 and 10488.— The cyst-walls vary considerably in thickness. At some points they are thin and transparent; at others they reach the thickness of about 2 cm. These solid areas also contain cysts, and in the small cysts is a blackish-colored fluid. The entire specimen is vascular, and in some places friable and apparently malignant.
On histologic examination the walls are found to consist in part of fibrous tissue, with a definite laminated arrangement. In many places necrosis has taken place, and the tissue presents a homogeneous appearance or takes the stain very poorly. At other points in the walls the connective-tissue cells have taken up much brown pigment, evidently from a long-standing hemorrhage. Here and there throughout the walls are slit-like spaces, the smaller ones surrounded by giant-cells * (Fig. 258) . The giant-cells really consist of large masses of protoplasm containing oval or round, deeply staining nuclei (Fig. 260), and some of these nuclei are four or five times the size of the surrounding ones. Where the cavities are larger, giant-cells may be seen clinging to one side of the cavity, other portions of the cavity being devoid of a lining (Fig. 259). At certain points are aggregations of giant-cells, and interspersed are small, slit-like spaces. One is instantly reminded of the giant-cells and slit-like spaces noted by Bondi, and on careful examination we found here and
~~I am fully aware of the frequency with which foreign-body giant-cells are prone to occur~~
in the walls of certain cysts and elsewhere, but the giant-cells in this case are rather unusual, hence I have described them more or less in detail.

Fig. 260. — Giant-cells in the Wall of an Adenocarcinomatous Cyst of the Ukachus. ( X 90 and 300 diam.) Gyn.-Path. Nos. 10368 and 10488. A. a seems to be a large, gland-like space filled with coagulated blood and exfoliated epithelium. It is lined with one layer of low cuboid epithelium, well seen at b. c is a large blood-vessel. Scattered throughout the stroma of the cyst-wall are giant-cells and quite a number of slit-like spaces lined with giantcells. Traversing the slit-like spaces (d) are delicate strands, one of which contains very small nuclei.
B. This shows an enlargement of the oblong area in A. The stroma consists of fibrous tissue. At a is a nest of cancer-cells which has retracted from the surrounding connective tissue. 6 is a deposit of calcareous material near the wall of a blood-vessel, c and d are slit-like spaces, c is lined with a ribbon of protoplasm showing nuclei scattered fairly evenly throughout it. It is impossible to detect any division of the protoplasm into individual cells. The space d is lined with a wide zone of protoplasm showing many nuclei, uniform in size and staining properties, equally distributed throughout the protoplasm, e is another slit-like space lined with a ribbon of protoplasm containing only a single row of nuclei. 42

642

THE UMBILICUS AND ITS DISEASES.

there crystals lying in the cavity, such as were also found by Bondi. Other portions of the tumor show gland-like spaces lined with one or more layers of epithelium (Fig. 261). The nuclei of the epithelial cells are oval and vesicular, or are deeply staining, and the epithelium itself is of the low cylindric variety. In some places the epithelium has proliferated to a moderate extent. The gland arrangement in

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Fig. 261. — Adenocarcinoma op the Urachus. ( X 90diam.) Gyn.-Path. Nos. 10368 and 10488. The growth at this point bears considerable resemblance to a papillocystoma of the ovary; it consists of large and small irregular spaces lined almost exclusively with one layer of cuboid or low cylindric epithelium, a is a very good example of one of the spaces with a projection into it from the side. This space is lined with one layer of cuboid epithelium containing relatively round and deeply staining nuclei. These nuclei are particularly well seen at 6. The granular contents in the gland-spaces consist of coagulated epithelial secretion. The epithelial elements in the left lower part of the picture have to a large extent melted away. The fibrous stroma of the growth contains very few nuclei, c is one of the blood-vessels in the stroma. From this picture alone one could not tell definitely whether the growth was malignant or not. That it is malignant, however, is definitely settled by a reference to Kig. I'll:',, and also by the fact that at operation metastases were found.

some places suggests a papillary formation (Fig. 262), and the gland cavities are filled with a homogeneous material that takes the eosin stain. The epithelial cells at other points are almost flat. There does not seem to be much variation in the size of the cells, and such a picture alone would suggest a papillocystoma. At other points the epithelium has proliferated markedly, so that we have what

MALIGNANT CHANGES IN THE URACHUS.

643

appears to be solid nests; or the epithelium has melted away, as is noted in colloid carcinoma.
There is no doubt we are dealing with a multilocular cyst that has become malignant. This cyst certainly belongs to a rare type. Of the malignancy, there can be no doubt, because metastases in the pelvic peritoneum were noted at operation (Fig. 263). It did not spring from the ovaries, as they were perfectly normal in

Fig. 262. — A Papillary- like Area in an Adexocarcixomatous Cyst of the Urachus. (X 90 diam.) Gyn.-Path. Nos. 10368 and 10488. The picture is a rather confused one. At a the complex papillary mass is seen covered with one layer of cuboid epithelium having round, uniformly staining nuclei. At b are two definite glandlike spaces. At c is a bluntish projection of the stroma into a gland-space, d indicates the stroma, consisting of spindleshaped connective-tissue cells. The gland-spaces are filled with a granular, homogeneous material seen at e. (For the appearances of the metastases see Fig. 263.)
size and distant from the growth. Its pedicle, as noted from the history, sprang from the top of the bladder. It will further be noted that during the removal of the tumor a large part of the peritoneum of the anterior and lateral abdominal walls had to be sacrificed. This tumor evidently originated from the urachus.
The mode of origin of the giant-cells has been of especial interest to me. It will be noted that these giant-cells have been found almost entirelv in the outer con

644

THE UMBILICUS AND ITS DISEASES.

nective-tissue wall of the large cyst, and that the cavities that they line are slitlike. This is particularly well seen in Fig. 258. Furthermore, in the vicinity of these slit-like spaces are well-formed giant-cells lying completely surrounded by stroma (Fig. 258, b). On examining the space b in Fig. 259, one gathers the impression that the tissue has been especially brittle, and that during the process of hardening the giant-cells may have split lengthwise; this impression is still further strengthened by examining the area c in Fig. 259. Here the protoplasm has apparently been split up into several long strands. At the upper end of this

Fig. 263. — Metastasis from Adenocarcinoma of the Urachus. ( X 90 diam.) Gyn.-Path. Nos. 10368 and 10488. o and a are blood-vessels. Scattered throughout the field are nests of epithelial cells. Although originally the growth was glandular, the metastases have tended to form solid nests. At 6, however, two gland-like spaces can be faintly made out. During the process of hardening the cancerous tissue tended to retract from the stroma. This is especially well seen at c. The stroma of the growth showed considerable small-round-cell infiltration.

area there is an intact giant-cell. The finer structure of the giant-cell is well seen in Fig. 260, B, d.
In an examination of a large number of ovarian cysts I have never seen a picture analogous to the one here depicted. To be sure, in very young dermoid cysts of the ovary, giant-cells are the rule, but here they are invariably lining or clinging to the walls of small cysts — such giant-cells are the embryonic stages of squamous epithelium.
Dr. William H. Welch informed me that he had occasionally seen giant-cells

MALIGNANT CHANGES IN THE URACHUS.

645

similar to these in the walls of cysts and elsewhere, and suggested that they might be foreign-body giant-cells. He further suggested the possibility of their developing around crystals. On careful examination of many giant-cells I found just one crystal. This was irregular in form. Whether the giant-cells in this case are foreign-body cells or not I cannot say. This point, of course, is of interest only to the pathologist.
Bondi reported a small umbilical cyst of unknown origin. He found quantities of giant-cells analogous to those here depicted (Fig. 266), and in his case some of the giant-cells surrounded crystals. Although his cyst was not malignant, it is of such interest in connection with my case that I shall here report it somewhat in detail.

A RARE UMBILICAL CYST. Bondi* reports this case from Schauta's clinic. The patient was a woman, sixty-two years of age. She had had three normal labors. About twenty months before coming under observation she noticed that the umbilicus was larger than usual,

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Fig. 264. — An Umbilical Cyst. (After Bondi.) The original tumor was 5 cm. in diameter. The drawing has been made from the hardened specimen, which was much contracted. Nearly two years before operation the patient had noted an enlargement at the umbilicus. The overlying skin was brownish in color, tense, and elastic. It was slightly compressible. H is the skin covering the cyst; Nr, the confines of the umbilical depression; P, a prolongation of the peritoneal cavity into the mass. The walls of the cyst were composed of two layers — an outer, consisting of whitish tissue, and an inner, homogeneous zone, grayish brown in color. The cyst contents were spongy, yellowish brown, and soft. (For the histologic picture see Figs. 265 and 266.)

Fig. 26.5. — Wall of an Umbilical Cyst. (After Bondi.) This is a section of the cyst-wall seen in Fig. 264. H represents the skin, with connective tissue immediately beneath it ; B, a dense layer of connective tissue. Rx, granulation tissue. In this are areas containing small spaces. These spaces, as seen in Fig. 266, are lined with giant-cells. The cells in this layer contain blood-pigment. The inner surface (F) consists of coarse and fine threads of fibrin.

and that the abdomen had increased in size. She had never noticed a tumor projecting outward beyond the level of the umbilicus.
At operation, at the umbilicus was a tumor 5 cm. in diameter, the skin over it being brownish in color. It was tense and elastic, showed no marked fluctuation, and was slightly compressible. The abdominal enlargement was due to a multilocular ovarian cyst the size of a man's head, with torsion of the pedicle to the extent of 180 degrees; the wall of the cyst was partially necrotic.
~~Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 190.5, xxi, 729.~~

646 THE UMBILICUS AND ITS DISEASES.
In the hardened specimen the umbilical cyst was 2.5 cm. in diameter. It lav over an outward prolongation of the abdominal cavity, much as a cap
would fit (Fig. 264). The walls of the
.v^^T^^- c y s ^ nac * two layers, the outer consist ■ > .'! "•' <. j n g f whitish tissue 2 mm. thick. It
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\ ii ^ v -F~'~' u; $?l£'Z •^N;* of a broad, homogeneous, gray-brown H%» . -, - : ^ tissue. The cyst contents were spongy, % %\Sj ! /<?^j.- M ?^ ,; l||-: yellowish brown, and soft. Its length } » ;f ' "^/v^C — *^^ in the hardened specimen was 2.5 cm., ^ l*^/j§^- '^" "<#^ : f and its greatest thickness, 1.5 cm. The v\'%fj|&/^/; )' ^,;f.-."--^'* *£• V outer wall of the cyst consisted of fibrous ,Ui ^ ^-^^^'v^^ tissue, which gradually passed over into s^- •*'-'* v *|^' the inner, homogeneous lining, consist'* V *'^ ;* 'o» '"■* ing of young fibrous tissue. This gradu"*%t£ j , v-** ally merged into the granulation tissue
~~" **- bx which lined the cavity. The granulation~~
fig. 266.— Giaxt-cells in the Wall of an u.mbili- tissue here and there contained blood-pigon i.) ment. Here and there near the inner
Scattered throughout the inner wall of the cyst
(Fig. 26.5) were aggregations of small, siit-iike spaces. surf ace were numerous spaces, often oc Some of these are lined with one layer of epithelium, CU lTmg ill groups. These Were regularly
others with giant-cells. The nuclei of the giant-cells .... ,-,-,. __ _ . o^^x
are uniform and fairly evenly distributed throughout lmed With giailt-CellS (t lgS. 265 and 266) .
the protoplasm. j n t nese spaces were crystals showing that
the spaces were not artefacts. Bondi says that it was not a dermoid, but a peritoneal cyst, into which a hemorrhage had occurred.
It is possible that these giant-cells were foreign-body giant-cells. As already pointed out, they bear a marked resemblance to those noted in the malignant cyst of the urachus I have just recorded so fully. (See Figs. 258, 259, and 260.)

LITERATURE CONSULTED ON MALIGNANT GROWTHS OF THE URACHUS AND URACHAL REGION.
Aveling: Brit. Gyn. Jour., 1886-87, ii, 56, 187.
Bondi, J.: Zur Kasuistik der Nabelcysten. Monatsschr. f. Geb. u. Gyn., 1905, xxi, 729.
Doran, A.: Stanley's Case of Patent Urachus with Observations on Urachal Cysts. St. Bartholomew's Hospital Reports, 1898, xxxiv, 33.
Doran, A. H. G.: Urachal Cyst Simulating Appendicular Abscess; Arrested Development of Genital Tract; with Notes on Recently Reported Cases of Urachal Cysts. The Lancet, 1909, i, 1304.
Fischer, H.: Die Eiterungen im subumbilicalen Raume. Volkmann's Sammlung klin. Vortrage, N. F., No. 89 (Chir. No. 24), Leipzig, 1894, 519.
Frank, T.: Zur Casuistik der Urachustumoren. Inaug. Diss., Wurzburg, 1893.
Graf, F.: Urachusfisteln und ihre Behandlung. Inaug. Diss., Berlin, 1896.
Hoffmann, C. E. E.: Zur pathologisch-anatomischen Veranderung des Harnstrangs. Arch. der Heilkunde, 1870, xi, 373.
Koslowski, B. S. : Ein Fall von wahrem Nabeladenom. Deutsche Zeitschr. f. Chir., 1903, lxix, 469.
Rotter: Blasencarcinom kombinirt mit Urachuscyste. Centralbl. f. Chir., 1897, xxiv, 604.
Wolff, C. C. : Beitrag zur Lehre von den Urachuscysten. Inaug. Diss., Marburg, 1873.

CHAPTER XXXVIII. BLEEDING FROM THE URACHUS INTO THE BLADDER.
The literature on this subject is a negligible quantity. W. Ramsay Smith * reports a case which, although somewhat obscure, may be mentioned here.
The patient, a female infant, was born August 3d. The labor was short, and the child brought away with forceps. The cord appeared to be normal. On the second night, August 5th, a large quantity of bright-red blood was noticed on the infant's binder. It appeared on that night only, and the nurse noticed that it was coming not from the cord,- but from the umbilicus at the side of the cord. Two days later (August 7th) the child had an attack of diarrhea, and there was a good deal of blood in the stools, and it was noticed that this blood was coming from the urethra. On August 8th the bleeding was very severe, there being over two teaspoonfuls at a time. The blood always appeared when the bowels moved, but it came from the urethra. The diarrhea ceased, and the bleeding stopped on August 9th. Smith thought that the bleeding took place from the hypogastrics, and escaped to the bladder along the urachus. Ballantyne felt somewhat reluctant to accept this explanation, but said that, under the circumstances, it was difficult to suggest any that was more satisfactory.
A few years ago, while discussing diseases of the umbilical region with Dr. Edward Reynolds, of Boston, he mentioned the fact that on several occasions he had noted bleeding from the urachus into the bladder. Later I wrote asking him kindly to furnish me with the data he had bearing on the subject. His reply was as follows :
"With regard to my recent hematuric case, the patient was a physician about thirty-five years old, from whom I removed the appendix about two years ago. She came to me on the seventh of February, saying that, after very hard and long automobiling over rough country roads a few days before, she had been seized by a sudden urgent desire to urinate, and had passed a quantity of bloody urine. Since then urination had been normal, but the urine was slightly blood-stained. She informed me that she had noticed that the first part of the urine was clear and that the blood came with the last few drops. When I first looked into her bladder the small amount of urine was clear (she had just emptied it). I inspected the trigonum and fundus of a normal bladder carefully in the knee-chest position, and, on turning the point of the cystoscope forward, found that in the interval the urine had become distinctly pink. I then emptied the bladder thoroughly with the evacuator, and saw a small stream of blood flowing from the orifice of the urachus. The patient has written me since that the hematuria stopped within forty-eight hours after her visit to me, and that there was no recurrence. I told her that I thought there was no other treatment than the removal of the urachus; that I should not advise that unless the symptoms were persistent; that I should advise
~~Smith, W. Ramsay: Obstet. Trans., Edinburgh, 1892-93, xviii, 53.~~
647

648 THE UMBILICUS AND ITS DISEASES.
it if the hematuria were recurrent. I asked her to keep me informed of her progress, and I think that she will do so.
This is not my first case of the kind. A good many years ago, when I was doing a large out-patient clinic and making a great many cystoscopic examinations, I saw a number of cases, I should guess from half a dozen to a dozen, in which minor vesical symptoms seemed to be associated with a reddened, eroded condition of the vesical mucous membrane immediately about a small orifice in the upper and anterior part of the bladder, which, after some study, I grew to consider as the orifice of a patent urachus, and which, on close inspection, I could recognize in a considerable proportion of bladders in which it was not making trouble. I believe that this slight anomaly is very common, and that it is a not unimportant lurking-place for bacteria in infected bladders. In at least two cases in these old days I saw bleeding from this orifice; I think in more than that number, but the conditions of the clinic made careful record keeping very difficult. I should say that the hematuria was transient but recurrent. I do not know the ultimate outcome. The patients in that clinic were all of a class which it is difficult to follow up afterward."
Dr. Reynolds' observation clearly demonstrates that in some cases blood does escape from the persistent urachus into the bladder. His suggestion that the urachal opening is probably the lurking-place of bladder infections is fully borne out by the cystitis frequently noted where a partially patent urachus exists.

CHAPTER XXXIX. TUBERCULOSIS OF THE PATENT URACHUS.
I have been able to find only two cases of this character in the literature. The first case was recorded by Briddon and Eliot, the second by Eastman.
Dr. Thacher, who made the pathologic report on the extirpated urachus in Briddon and Eliot's case, after giving a very careful and guarded description, decided that the condition was probably tuberculous. Dr. Eastman sent us his specimen and we have been able to demonstrate tubercle bacilli in the urachus.
"Tubercular Degeneration of the Patent Urachus in the Adult.* — R. M., aged nineteen, Roumanian; married. Admitted July 17, 1899. No tubercular family or personal history. The patient has always been well until five weeks ago, when she began to have slight pain, with heat, redness', and swelling in the region of the umbilicus, the navel having previously been always normal in appearance. The symptoms increased for two weeks, at the end of which time there was a small red tumor, the size of a pea, in the region of the umbilicus. During this time the patient suffered intensely from severe, sharp pain, almost constantly present, in the hypogastric region, with well-marked vesical tenesmus, increased frequency of micturition (often voiding urine every hour), and occasionally a small amount of blood in the urine. At the end of the two weeks the swelling opened spontaneously, discharging some cloudy fluid with a uriniferous and foul odor, the pain and swelling soon subsiding. About four days after the discharge of fluid at the umbilicus, she ceased to pass water normally, and since then she has had a constant discharge of cloudy fluid of a uriniferous odor, at times slightly blood-stained, through the opening at the umbilicus. She has lost considerable flesh and strength during the period of five weeks.
"Physical Examination. — The patient is markedly anemic and is apathetic. The facies is flushed; the tongue is moist and not heavily coated. The superficial glands are not enlarged. In the heart there is a hemic murmur over the pulmonic area, systolic in time. Percussion of the lungs is normal, but the breathing is rather poor. The abdomen is soft, retracted, and no masses can be felt. At the inferior portion of the umbilicus is a small sinus with everted and ulcerated edges, which discharges a seropurulent fluid of uriniferous odor. A probe introduced into the sinus goes downward and extends evidently as far as the bladder. The bladder does not percuss high, but there is some tenderness on pressure over the suprapubic region. Urine analysis at the time of admission showed very turbid and cloudy urine, with specific gravity of 1014, 15 per cent of sediment, reaction strongly alkaline, and odor foul and ammoniacal. There was 10 per cent of albumin, no blood, a large amount of mucus, much pus, and many vesical cells, with many crystals of triple phosphate. No casts were found. She was placed upon bladder irrigations twice daily, with warm 0.5 per cent, boric-acid solution, and salol (gr. v)
~~Briddon, C. K., and Eliot, E.: Med. and Surg. Reports, Presbyterian Hospital, New York,~~
January, 1900, iv, 30.
649

650 THE UMBILICUS AND ITS DISEASES.
three times a day. There was no improvement under this treatment, either in the character of the urine or in the patient's general condition, except that she had slightly less pain. At the end of a week the bladder irrigation was changed to carbolic acid, in strength of 1 : 120. This also seemed to have no effect upon the urine, frequent examinations up to the time of operation giving about the same result. As at the first analysis, the specific gravity never rose above 1014; the urine always remained alkaline and was full of pus and mucus. The temperature course was irregular, varying between 99.5° F. and 102° F., and did not seem to be influenced in any way by the bladder washing. During a period of several days of fairly constant low temperature the patient gave a moderately characteristic tuberculin reaction. The average daily amount of urine voided by the urachus varied from 15 to 20 ounces. At intervals of several days she voided a few drams or an ounce of urine per urethram.
" Owing to the obstinate, unyielding cystitis, it was thought advisable to do a suprapubic cystotomy for purposes of drainage.
" Operation (August 25th) . — Dr. Eliot. Nitrous oxid and ether; asepsis; dorsal position. A catheter was introduced through the urethra into the bladder and urine was withdrawn. Four ounces of warm 1 per cent boric-acid solution were then gently thrown into the bladder by a fountain syringe, six ounces of water, injected into a Barnes dilator, having been previously inserted into the rectum. A 23^-inch median incision was then made above the pubis and deepened down to the space of Retzius. The soft cellular tissue here being pushed aside and the bladder presenting, two silk sutures were passed in a longitudinal fashion through its wall, separated by a distance of one inch, these sutures being placed for purposes of traction. The bladder was then opened between the silk sutures, the boricacid fluid pouring out into the wound. The incision in the bladder-wall being subsequently enlarged upward, disclosed the urachus opening into the fundus of the bladder. There were several small areas of ulceration on the posterior wall of the bladder, and parts of the ulcers, together with a portion of the urachus, were secured for microscopic examination. The ulcerated areas upon the bladder-wall were cauterized with a thermocautery. The lumen of the urachus was packed with a strip of iodoform gauze, the cavity of the bladder being drained through the suprapubic wound in the usual way by means of a tube.
"Report by J. S. Thacher, Pathologist.- — A. Minute fragment of tissue from urachus. Microscopic examination shows a mass of smooth muscle and connective tissue. The muscle-cells vary somewhat in size and shape, and are irregular in arrangement.
"B. Minute fragments from base of bladder. The epithelium is partly destroyed, and the tissues are much inflamed. The inflammation appears to be of some standing.
"The bladder was drained very satisfactorily for ten days by the siphon drainage apparatus, the suprapubic wound remaining comparatively clean and dry. The patient's temperature was increased for six days following the operation. Recovery was uneventful. Bladder irrigation with carbolic acid, 1:40, was employed, when the drainage apparatus was dispensed with, the urine clearing up slightly and the pain becoming much less severe. She seemed to improve in general health to a moderate degree. Urine was not voided normally after the suprapubic operation had been performed.

TUBERCULOSIS OF THE PATENT URACHUS. 651
"September 25th: Urine, for about one week, has had much less pus and mucus in it, and hypogastric pain has been much less severe. It was then decided to attempt an extirpation of the patent urachus, leaving the suprapubic wound unmolested.
"Operation (September 27th). — Dr. Briddon; nitrous oxid and ether; asepsis; dorsal position. A median incision was made from the umbilicus down to the suprapubic wound of the previous operation, exposing the linea alba, which was split up in the line of the incision, exposing granulation tissue forming the wall of the patent urachus. By blunt dissection this tissue was then dissected free from the underlying thickened peritoneum, during which process the urachus was opened longitudinally through a portion of its extent. The walls of the urachus were nearly a quarter of an inch thick, and their diameter was about half an inch. At its point of junction with the bladder it was cut transversely and removed, the general cavity of the peritoneum not being opened. A clean surface was thus left, whose floor was formed by the thickened peritoneum, and its sides by the divided portion of the linea alba. This tract was closed by eight interrupted chromic catgut sutures, passing from one side to the other through the skin and linea alba, thus approximating the raw edges of the tract. A sterile dressing was placed on the sutured wound, a rubber drainage-tube and iodoform gauze being left in the suprapubic wound.
" Report of J. S. Thacher, Pathologist. — Extirpation of patent urachus. Microscopic examination : Granulation tissue ; spots of marked infiltration by leukocytes; several small necrotic spots; many giant-cells; some tissue resembling tubercle tissue — probably tubercular.
" Recovery from the operation was uneventful. The bladder was drained satisfactorily for ten days, the wound for urachus extirpation healing by primary union without complication. Her general health rapidly improved, and she had gradually less hypogastric pain and discomfort. For a few weeks the patient voided no urine normally, all being discharged through the suprapubic wound. Since then she has passed almost every day one or more ounces of urine per urethram, in gradually increasing quantity. Her general condition is very much improved, the suprapubic wound is steadily closing, and urinary analysis now gives but 3 per cent, of albumin, with much less pus and mucus.
"Repeated examination of urine failed to discover any tubercle bacilli, and careful physical examination by G. A. Tuttle failed to detect any evidence of pulmonary or other visceral tuberculosis.
"Examination conducted by Dr. Tuttle, in the pathologic laboratory, of the small ulcers which were excised from the wall of the bladder at the time of the first operation, failed to yield positive indications of tuberculosis; conclusive evidence at last was furnished by the examination by Dr. Thacher of the urachus itself, removed by Dr. Briddon at the time of the second operation. Inferences are always uncertain, and although the statement that the tubercular process originated in the patent remnant of the duct itself is not entirely justifiable, nevertheless, the fact remains that examination of its wall after removal showed much more abundant evidence of tuberculosis than did the portion of the bladder-wall removed earlier by suprapubic cystotomy."
In the case under discussion the removal of the urachus was accomplished without opening the general peritoneal cavity.

652

THE UMBILICUS AND ITS DISEASES.

I was particularly anxious to see a section from this case, and accordingly wrote Dr. Thacher. In his reply, dated New York, April 8, 1914, he gave me the results of his examination, but said the original slide could not be located.
Tuberculosis of the Urachus.* ■ — Dr. Eastman has just recorded a very interesting case of tuberculosis of the urachus in a girl aged nineteen.
"Family History. — Father died of cancer of the stomach at the age of fifty-one; one brother died during infancy of meningitis; history otherwise negative, particularly as relates to tuberculosis or neoplasms.

Fig. 267. — Tuberculosis of the Urachus.
This is a low-power photomicrograph from Dr. J. R. Eastman's case. At a is an area of caseation surrounded by tissue closely resembling that found in tuberculosis. The outer walls are composed of non-striped muscle and fibrous tissue. Scattered throughout this tissue are localized foci more or less characteristic of those noted in tuberculosis. The areas b and c are very suggestive of tubercles.
The high-power picture of the area b is shown in Fig. 268; that of the area c, in Fig. 269.

"Personal History. — Typhoid at seventeen with good recovery; history otherwise negative; patient married two years and four months; one pregnancy, child living and well; at no time night-sweats or protracted cough; no characteristic temperature history; no other evidences of tuberculosis.
"Menstrual History. — Menstruation began at twelve; regular; duration five days and free; no change in type since marriage or labor.
"Urination. — No increase in frequency, no nocturnal urination. Three diurnal urinations; never any blood or burning or stinging.
"History of illness for which patient entered hospital. — This trouble began ten
~~Eastman, Joseph Rilus: Amer. Jour, of Obstetrics, 1915, lxxii, 640.~~

TUBERCULOSIS OF THE PATENT URACHUS.

653

months before entrance. While working in the garden, pain was felt at a point in the mid-line of the abdomen between the symphysis pubis and the umbilicus. At this time patient noticed a lump at the point designated, the size of a small apple. There was not much actual pain nor soreness. The mass did not increase in size but the tenderness remained. This condition persisted for three months when a pin-point opening appeared in the mid-line of the anterior abdominal wall, half-way between the symphysis pubis and the umbilicus. This opening discharged a clear watery fluid for about a week. Then a serous crust closed the opening. The opening again discharged after about a week, continuing to do so for one week and again the crust was formed. This process of closing and opening continued for several months. The size of the tumor did not change. The tenderness still persisted. There had never been any disturbance of the bladder, intestines or uterus.

a
•1

b

x

d c
Fig. 26S. — An Area Suggesting a Tubercle. This picture is a high-power magnification of the area b in Fig. 267. Its confines are indicated by x and x. Scattered throughout this area are spindle cells and round cells. At a and b are giant-cells. At c the cells are so arranged as to suggest a small gland. At d is a large cell bearing a strong resemblance to a squamous cell.

The discharge had always been free from odor. She is positive that the discharge never had a urinous odor.
"Status Prsesens. — The patient's general health was unimpaired. Urinalysis and physical examination of the chest and abdomen were negative. There were no evidences of pulmonary tuberculosis nor of tuberculosis elsewhere. Through the discharging sinus below the umbilicus a small sound could be passed downward behind the symphysis pubis.
"Operation. — The fistulous tract, upon being dissected free, was found to pass downward from the discharging orifice, coursing in front of the peritoneum, crossing the space of Retzius and terminating in a thin cord attached to the anterior bladder wall in the median line and near to the vesico-urethral junction. Upon being split open the definite tube-like structure was found to be thin-walled, showing no evidence of inflammation or other pathological condition except near the external discharging orifice, where an ulcerated mass about 2 cm. in width was situate upon the dorsal wall of the tube.
"Cystoscopic Examination. — Bladder distended with 8 ounces of water for

654 THE UMBILICUS AND ITS DISEASES.
examination: vesical sphincter normal in outline; trigone normal; both ureteral openings and the mucosa surrounding them were normal as to contractility and rhythm. There were no ulcers, tubercles, or any other abnormalities upon the floor of the bladder. The vesical roof was examined carefully and this portion of the bladder was found to be absolutely devoid of any ulcer, tubercles, opening, or any other abnormality of the vesical mucous membrane; and there was not the slightest hint of any communication with the patent urachus.
"•Chemical and Microscopic Urinalysis. — After operation as before the urine was normal.
••Clinical Course since Operation. — "Wound closed slowly; there have been no

Fig. 269. — A Tubercle from Dr. Eastman's Case of Tuberculosis of the Urachus.
This L= a high-power picture made by Mr. H. Schapiro from Fig. 267 at c.
The tubercle is oval in form and is fairly well differentiated from the surrounding stroma. The cells of the tubercle are spindle-shaped, oval, round, or irregular. In the lower part of the tubercle is a large giant cell containing a large number of nuclei arranged chiefly in its center. The grouping of the nuclei in this giant cell resembles to some extent that usually found in foreign-body giant cells, but the picture as a whole is strongly suggestive of tuberculosis.
symptoms of any kind relating to the genitourinary organs; there is no evidence of return of the disease."
I wrote Dr. Eastman asking if he could send me sections of the urachus. This he promptly did. An examination of them shows the following:
The central portion of the specimen consists of granular tissue containing a few cells. It looks very much like caseous tissue (Fig. 267a). External to this is a tissue made up of young connective-tissue cells and fairly large round cells with small round nuclei, and beneath this a zone containing a few giant cells. The outer wall apparently consists of non-striped muscle and connective tissue infiltrated with small round cells. In this are round or oval areas containing aggregations of epithelioid cells with giant cells scattered here and there throughout them [Figs. 208 and 269;. External to this zone is the surrounding adipose tissue. The entire picture strongly indicates tuberculosis of the urachus.
Dr. Benjamin O. McCleary and Dr. George L. Stickney have each independently demonstrated tubercle bacilli in the sections; consequently this is a definite of tuberculosis of the urachus.

@@ Line 2,241: / Line 2,241: @@
-CHAPTER XXXIII.
+==Chapter XXXIII. Abscesses in the Anterior Abdominal Wall between the Umbilicus and Symphysis due to Infection of Urachal Remains or of Urachal Cysts==
-ABSCESSES IN THE ANTERIOR ABDOMINAL WALL BETWEEN THE
-UMBILICUS AND SYMPHYSIS DUE TO INFECTION OF URACHAL
-REMAINS OR OF URACHAL CYSTS.
 Report of a personal observation.
@@ Line 2,900: / Line 2,894: @@
+==Chapter XXXIV. Urachal Cavities between the Symphysis and Umbilicus Communicating with the Bladder or Umbilicus or with Both==
+General consideration.
-CHAPTER XXXIV.
-URACHAL CAVITIES BETWEEN THE SYMPHYSIS AND UMBILICUS
-COMMUNICATING WITH THE BLADDER OR UMBILICUS OR
-WITH BOTH.
-General consideration.
 Symptoms.
 Differential diagnosis.
 Treatment.

Book - Umbilicus (1916): Difference between revisions

Revision as of 11:54, 26 October 2018

Contents

Embryology, Anatomy, and Diseases of the Umbilicus together with Diseases of the Urachus

Preface

Contents

List of Illustrations

List of Plates

Chapter XXXII. Large Urachal Cysts

Chapter XXXIII. Abscesses in the Anterior Abdominal Wall between the Umbilicus and Symphysis due to Infection of Urachal Remains or of Urachal Cysts

Chapter XXXIV. Urachal Cavities between the Symphysis and Umbilicus Communicating with the Bladder or Umbilicus or with Both